The Royal College of Radiologists Census of Clinical Oncology Highlights a Growing Crisis and a Service at Breaking Point. Dr Nicky Thorp Outlines the Findings, and Details the Key Actions Necessary to Achieve a Better Balance Between Oncology Workforce Numbers and Patient Demand
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The 15th annual Royal College of Radiologists (RCR) clinical oncology census report1 was published in June 2023 against the backdrop of what many commentators describe as the worst crisis in the 75-year history of the NHS.2 This year’s census findings prompted an unprecedented amount of media interest,3–6 reflecting concern about a severe and worsening shortage of oncologists in the UK coupled with an unrelenting growth in demand for cancer services.7
Each October, the census questionnaire is sent electronically to the heads of all 60 oncology departments in the UK, with the findings published the following summer. This is a comprehensive and accurate reflection of the oncology workforce in the UK, with a response rate that is consistently 100%, demonstrating the value that oncologists place upon it. The census mainly pertains to the clinical oncology workforce,1 but some less granular data are also collected on the medical oncology workforce.
Key Findings for 2023
- There are currently 998 whole time equivalent (WTE) clinical oncology consultants and 547 WTE medical oncology consultants working in the UK, with 77 WTE speciality and associate specialist (SAS) doctors and 544 trainee clinical oncologists1
- Although there has been an increase of 5% WTE clinical oncologists during the past year1, 200 additional new consultants are required to keep up with the 165,000 extra new cancer patients per year who require non-surgical treatments8,9
- In 2022, there were 175 fewer clinical oncology doctors than required,1 representing a 15% shortfall; without meaningful action, this shortfall is set to increase to 25% in 20271
- 33% of clinical oncologists are working less than full time, including a significant proportion of doctors aged >55 years1
- 49% of clinical oncologists are considering reducing their hours1
- 20% (217) of clinical oncology consultants are due to retire in the next 5 years, and 40% in the next 10 years1
- The proportion of costly locum oncologists has doubled from 4% in 2020 to 8% in 20221
- There are significant inequalities in the distribution of oncologists across the UK, with 10.5 oncologists per 100,000 people aged >50 years (those most likely to develop cancer) in London, but only 3.1 oncologists per 100,000 people aged >50 years in North and West Wales.1
Impact on Patient CareThe results describe a situation familiar to oncologists across the UK—workforce growth is not keeping pace with rising workloads.1,10 Hard-pressed departments are under immense pressure to deliver high standards of care against a background of:
- the COVID-19 cancer backlog1
- an increase in the number of patients with significant comorbidities, reflecting the ageing population
- an increase in the availability of systemic anticancer therapy (SACT) regimens throughout the patient pathway that have been approved through NICE and the cancer drugs fund11,12
- radiotherapy that is becoming more technically complex and time-consuming to plan and deliver.
There are equally concerning delays for patients requiring SACT. The delivery rate of SACT is increasing at 6–8% per annum, but the number of new consultants is not sufficient to meet this demand.1,11 In 55% of cancer centres, patients are subject to delays in initiating SACT most or all months,1 and only 62% of patients in England started their treatment within 2 months of an urgent GP referral in December 2022.1,13 Staff are having to find unsatisfactory workarounds to prevent collapse of systems—working harder, keeping chemotherapy units operating for longer hours, triaging patients so that ‘less urgent’ cases wait longer, or (most reluctantly) explicitly rationing treatments.
There are similar, if not greater, pressures in acute oncology services (AOS). Acute oncology is a growing and important aspect of specialist oncology provision that offers cancer-specific expertise by oncology teams in an acute hospital setting.14 A well-functioning AOS removes some pressure from hard-pressed medical and surgical teams.14 AOS intervention has been shown to improve the quality of patient care, avoid unnecessary investigations, and reduce length-of-stay.14 But development and funding has been piecemeal, and provision is inconsistent across the UK.14 Workforce shortages deepen these inequalities further, as radiotherapy and SACT delivery are prioritised over AOS. Data from the RCR census demonstrate that only 22% of cancer centres can provide 24-hour AOS, and 37% offer no dedicated assessment or admissions unit.1 As a result, emergency cancer patients, often suffering the toxic effects of SACT and radiotherapy prescribed by oncologists, are managed by teams unfamiliar with the protocols and their side effects.
Impact on Clinicians
Inevitably, working under such relentless pressures has an impact on staff morale. Inability to offer adequate standards creates chronic stress and injury to morale, and leads to burnout. The 2023 census confirms that 50% of clinical oncologists are burnt out,1 and 96% of heads of service are worried about stress and burnout.1 This is leading to a premature loss of workforce, with 75% of those who retire leaving before the age of 60 years.
There is an inevitable knock-on effect on important non-clinical activities, such as teaching and training—which should be part of a consultant's routine—and a growing reluctance to take on managerial and other leadership positions. With insufficient time to devote to strategic issues, innovation in delivery and adaptability are stifled; 98% of heads of service expressed concern about the lack of time that consultants have available to commit to service improvement.1
Recommendations for Change
The picture painted by the 2023 RCR clinical oncology census is that of growing demand without commensurate growth in the number of consultants to care for patients.1 This perfect storm is eroding hard-won improvements in cancer care and increasing rates of burnout and dissatisfaction among oncologists. It is further exacerbated by challenges in recruiting and retaining staff.1 However, the RCR believes that with sufficient ambition, collaboration, and funding this stark situation can be reversed; with a systematic approach to the layers of problems and an emphasis on implementation of recommendations, we can start to repair cancer care in the UK.1
The RCR recommends a three-pronged approach focused on increased recruitment, better use of consultants’ time to improve wellbeing and productivity, and an emphasis on measures to retain staff.
1. Encourage More Trainee Doctors to Consider a Career in Oncology
Health Education England increased the number of oncology national training numbers in 202110 and 2022.15–17 However, fill rates have been disappointing,1 partly due to negative perceptions of the role.18 Oncology is erroneously seen as more difficult, depressing, and demanding than other specialties, a misunderstanding that may be due to a lack of exposure in medical school and internal medicine training (IMT).18 Respondents to a recent RCR Insight Panel survey were asked to consider what the negative perceptions of clinical oncology might be. Common answers included the radiation physics aspect of the curriculum (64%), poor patient prognoses (45%), and high workload (40%). Many respondents also cited a lack of exposure for undergraduates, foundation doctors, and IMTs to the specialty.19
Historically, oncology has barely featured in the undergraduate curriculum.20 This is changing—most medical schools now offer a 1-week oncology placement, and others such as the University of Liverpool offer extended placements.21 Although this adds pressure to oncology services and educational and clinical supervisors, it is an investment in the future. The RCR also works closely with the British Oncology Network for Undergraduate Societies, successfully raising the profile of oncology at medical schools and encouraging students to consider a career in oncology.22
To promote oncology during IMT, the RCR is supporting open evenings in radiotherapy centres to showcase the speciality, and is exploring a potential promotional campaign in collaboration with NHS England.
Some heads of service report that some hard-pressed trusts are reluctant to commit to funding their component of additional training places. The RCR has produced a template business case which can be adapted for local use to support and justify investment in additional oncology trainees.1,23
On average, it takes 9 years to train a consultant in oncology,1 so these longer-term solutions will not solve the immediate problem. But there is scope to bolster the quality and volume of the NHS workforce by ethical recruitment of international medical graduates (IMGs) through short-term global education and exchange programmes. IMGs are recruited for a short period of time (for example, 3 years) on an ‘earn, learn, and return basis’.1,10,24 This supports the NHS and also benefits the graduate and the health service in their country of origin, offering training and a valuable global perspective and experience.1
Reliance on global recruitment should not be a long-term solution, given higher IMG attrition rates and ethical concerns; 89% of UK graduates who took up a licence to practice in 2015 were still licensed in 2021 – this was only the case for 66% of IMGs.10
2. Expanding Consultant Capacity and Professional Development
Trusts and health boards should ensure that every doctor, including SAS doctors and those working less than full time, has 1.5 supporting professional activities (SPAs) protected in their job plan for non-clinical commitments.1 Existing job plans and ways of working must be adapted to increase a consultant’s capacity to enable professional development, training, and teaching and leadership roles. We envisage a number of ways that this could be achieved in the medium term.
In recent years, there has been an expansion of multiple IT systems. Some, such as the picture archiving and communication system (PACS), have transformed the way we operate for the better,25 but more often they result in consultants spending an increasing proportion of time on routine administrative tasks, such as arranging patient appointments. This leads to a hidden substantial reduction in consultant productivity. These systems should be designed to adapt to the specific requirements of the NHS. IT systems should facilitate devolution of routine administrative tasks away from consultants, allowing them to work ‘at the top of their licence’ for the benefit of the whole health system.26,27
There are also opportunities to expand capacity through skill mix and team working within the current workforce.10 Skill mix refers to the provision of care based on expertise and competencies rather than job title.1,27–29 Although many oncology services have embraced and developed skill mix to the benefit of staff and patients, it has not been universally adopted, and there are barriers to extending the concept, such as workforce shortages in allied health professional (AHP) groups.30
Consultant team working helps to streamline patient care while removing pressure from an individual consultant as a single point of failure.1,27 Historically, there have been concerns that the advantages of a consistent consultant–patient relationship may be lost with team working. Such pitfalls can be avoided by adopting alternative ways of working (such as, pre-clinic ‘huddles’ and a willingness to follow clear protocols). Excellent communication within teams and an equitable approach to distribution of workload is also necessary.29,31
An ideal team structure may consist of two or more consultants working alongside AHPs (for example, specialist nurses, radiographers, and pharmacists) and administrative support,32 supported by SAS grade doctors, IMGs, and physician associates. Trainees remain vital members of the team, but these structures enable a greater commitment to high quality teaching provided by all team members.
Although not a panacea, artificial intelligence (AI) applications also show promise as a useful tool in the radiotherapy planning pathway, for example, through auto-contouring of organs at risk and anatomically based treatment volumes. Consultants often perform contouring outside of their normal working hours because job planning has not kept pace with the temporal requirements of modern radiotherapy.33 However, consultants will still need to carefully check machine-generated contours, so it is important that commissioners are aware that the use of AI may not result in a clearly apparent significant time saving. But it is likely that consultants would not need to work as often in the evening and at weekends, which would improve wellbeing and reduce the risk of burnout. Less time spent contouring may also free up time for radiotherapy peer review.34,35
Finally, consideration should be given to further rollout of pre-existing proposals, such as the introduction of patient-initiated follow up36 and streamlining of multidisciplinary teams (MDTs).
3. Retaining Existing Clinicians and Healthcare Professionals
Reducing staff attrition when appropriate is the third variable in the workforce equation. This involves an emphasis on tackling aspects of NHS working that encourage otherwise committed staff to either work abroad in better remunerated posts with superior working conditions or to retire early. In many instances, it requires a revolution in the way the NHS treats its staff to undo the erosion of pay and conditions experienced over the past 10 years. For most doctors, pay is an important driver of wellbeing and job satisfaction, but additional improvements can be made to doctors’ everyday working lives to ensure that they feel valued and empowered.
In addition to improvements to IT systems, other examples are:
- flexible working patterns which evolve over the course of a career10
- protected break times
- break areas with a free supply of hot and cold beverages37
- hot and healthy food available for all staff to purchase 24 hours a day, 365 days a year
- dedicated workspaces
- sufficient car parking, subsidised for those who have to travel between multiple trusts during a working day
- ability to book leave with ease and receive timely confirmation
- support for childcare
- non-clinical staff areas that are cleaned regularly and subject to appropriate maintenance standards
- mentors for newly appointed consultants
- quality-control of appraisals to ensure that they encompass wellbeing and work–life balance38
- executive teams that visibly and actively support wellbeing initiatives, such as Schwartz rounds.39
The NHS Long Term Workforce Plan
The RCR has long called for a fully funded workforce plan for the NHS to address the workforce crisis consistently described in the annual RCR census. Therefore, we welcome the clear agenda and roadmap outlined in the NHS Long Term Workforce Plan,37 published in July 2023, which we recognise as a significant step towards ensuring a sustainable and resilient NHS workforce. The key is delivery, and the necessary and substantial uplift in funding to facilitate this. We note the new funding which is attached to the plan. But the proposals only go so far, and clarity is needed on how the Government and NHS England will guarantee that retention measures are implemented at a local level.
The 2023 RCR Census undoubtedly paints a bleak picture of a growing workforce crisis across oncology. It describes a system stretched to its limits, barely able to cope with increasing volumes and complexity of work. But change for the better can be affected through vision, collaboration, and a realistic uplift in funding. With investment from commissioners, a willingness of trusts to support recruitment and retention strategies, and a consultant body amenable to embracing different ways of working, there is potential to reverse the decline. The alternative is an inexorable erosion in the standards of cancer care in the UK, and declining staff morale. The result will be a poorer patient experience and increased cancer-related deaths and morbidity. This is unacceptable in a country as wealthy as the UK, and should not be tolerated by patients and their families, cancer professionals, or policy makers.