This report is solely for the use of client personnel.

No part of it may be
circulated, quoted, or reproduced for distribution outside the client
organisation without prior written approval from Candesic.
Mansfield
Advisors
The Changing Market for Doctors –
What You Should Know in 10 mins!
Dr Victor Chua
27 February 2013
SUMMARY
• Why you should pay attention: Career planning matters!
• Making lateral transitions in medicine is more difficult than in other professions
• Case study: cardiothoracic surgery
• Economics are not on your side
• Medical school admissions have doubled
• The number of consultants has also almost doubled
• …during a period of big increases in NHS spending
• But the years of expansion are over, and NHS spending is likely to be flat for many years
• A shift in the nature of medicine
• Greater workload in managing long term conditions such as diabetes, heart disease, pulmonary disease
• The surgical specialities over-recruited in the past, leading to fewer NTN’s going forward
• While the demand for most types of surgery has increased due to an ageing and longer-living population, some
types of surgery have been replaced by newer surgical techniques or medical therapy
• Varicose veins
• Benign prostatic hyperplasia by transurethal resection (TURP)
• Gallstones
• General practice as a career
• Drivers for growth in general practice
• Demand for general practice
• General practitioners as small businessmen
• Partnership model in general practice
• Careers for doctors outside medicine
Making lateral transitions in medicine is more difficult than in other professions
Source: Candesic Analysis
MEDICINE AND LAW CAREER PATHS
Medical School
6 years
F1/F2
2
years
Speciality Training
3 – 8 years
Fellowships,
MD, PhD
1 – 3 years
Consultant
Law School
3 years
Associate / Senior Associate
6 – 8 Years
Partner Senior Partner
Medicine
City Law
(Solicitor)
LPC
1 year
Training
Contract
2 years
• Seniority generally retained if changing
speciality
• Due to specific knowledge, need to
restart in order to change speciality
• Compared to other professions, lateral changes are are more challenging in medicine:
• A higher level of specific knowledge is required in order to move specialities, meaning
seniority is not retained during transition
• The need to do unpaid fellowships in competitive specialities limits accessibility for doctors
without family wealth
• Choosing a growing area is therefore more important for medical career progression than in other
professions
3
In the mid 2000’s, percutaneous coronary interventions (PCI) by interventional cardiologists started to replace the need for coronary
artery bypass grafts (CABG), resulting in a fall in the demand for cardiothoracic surgeons in the mid 2000’s
PCI: Percutaneous coronary intervention, done by invasive cardiologists or radiologists in an angiography suite through a small incision
CABG: Coronary artery bypass graft, done by a cardiothoracic surgeon in a laminar flow theatre, “Open heart surgery”
Source: Hospital Episode Statistics: K40.1- K49.9; K75.1 - K76.1; PTCA.org “History of angioplasty”; Candesic interviews
TREATMENT FOR CORONARY ARTERY DISEASE, ENGLAND, VOLUMES
• In the mid 2000’s, many cardiac surgeons finishing their registrar training were unable to find consulting posts at the end of their
long training.
• The first angioplasty was done by Gruntszig in 1977. PCI (with stenting) started to replace CABG in the USA in the mid to late
1990s. The trend became pronounced in the UK about seven years later. As a profession, cardiothoracic surgeons were
uninterested in training to perform PCI, opening up the field to interventional cardiologists
• The surplus of cardiothoracic surgeons was entirely foreseeable. But no action was taken to avert it
PCI has increased whilst CABG has decreased
‘000s
“In all honesty, we (the cardiac
surgeons) missed the boat when
Andreas Gruntzig came to this
country and the surgeons paid little
heed to his catheter work.”
Atiq Rehman, M.D., FACS
Performed by interventional
cardiologists
Performed by cardiothoracic
surgeons
The fall in the demand for CABG’s can be seen in the number of cardiac surgeons employed in the NHS in the mid 2000’s
Source: Centre for Workforce Intelligence, 2011
CARDIOTHORACIC SURGEONS BY GRADE
• In 2003-2005, the number of
speciality trainees grew by over
20%, as fully trained surgeons
were unable to secure a
consultant post. Some hung on
and eventually secured a post;
others retrained in other
specialities
• By 2011, the number of
consultants leaving the
profession due to retirement
started to match the supply of
qualifying trainees. The Centre
for Workforce Intelligence
projects a declining number of
cardiothoracic surgeons due to
retirement
• These numbers include both
predominantly cardiac and
predominantly thoracic
surgeons, plus paediatric and
transplant surgeons
SUMMARY
• Why you should pay attention: Career planning matters!
• Making lateral transitions in medicine is more difficult than in other professions
• Case study: cardiothoracic surgery
• Economics are not on your side
• Medical school admissions have doubled
• The number of consultants has also almost doubled
• …during a period of big increases in NHS spending
• But the years of expansion are over, and NHS spending is likely to be flat for many years
• A shift in the nature of medicine
• Greater workload in managing long term conditions such as diabetes, heart disease, pulmonary disease
• The surgical specialities over-recruited in the past, leading to fewer NTN’s going forward
• While the demand for most types of surgery has increased due to an ageing and longer-living population, some
types of surgery have been replaced by newer surgical techniques or medical therapy
• Varicose veins
• Benign prostatic hyperplasia by transurethal resection (TURP)
• Gallstones
• General practice as a career
• Drivers for growth in general practice
• Demand for general practice
• General practitioners as small businessmen
• Partnership model in general practice
• Careers for doctors outside medicine
Medical school admissions have doubled since 1990, despite the population remaining constant. Much of the increase is
female
Source: Webster & Spavin: ‘Who are the doctors of tomorrow and what will they do?’; ONS – 1971 to 2010 population estimates
MEDICAL SCHOOL ADMISSIONS
UK Medical School Intake, Population of England (m) 1971-2004
6
• Since the mid 90s, there has been an
huge growth in the UK medical school
intake, which is only now levelling off
at around 8,000 admissions per year
• The demographic of the intake has
also shifted; females now account for
around 60% medical school
admissions, compared to below 50% in
1990, and just 25% in 1960
• The rate of increase in medical
admissions has far outstripped the rate
of population growth, and will therefore
increase the number of doctors per-
capita
9,000
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
50m
40m
30m
20m
10m
0
Population of England (m)
Female admissions to medical
school
Male admissions to medical school
The number of consultants has gone up by 60% in ten years
Source: NHS IC – NHS Staff 2001 – 2011 Overview
GROWTH IN THE MEDICAL WORKFORCE
Number of staff (Full Time Equivalents)
7
92,910
102,344
114,470
121,264
132,683
134,713
Consultants
GP Providers
(Partners)
GP Registrars,
Retainers and
Others
Doctors in Training
Other medical
workers
• Since 2001, the medical workforce
has grown at a rate of 3.8% year
on year
• The rise in number of consultants
has outstripped the rate of growth
of the workforce, showing 4.8%
year on year increases. This is
due to:
• Increases in the number of
training positions, as a part of
planned NHS expansion
• Consultants working into later
age
CAGR
3.8%
8
But the years of NHS expansion are over, and NHS spending is likely to be flat for many years
Source: ‘Comprehensive Spending Review 2010’ HM Treasury; Candesic analysis
SPENDING REVIEW 2010 – HEALTH FORECAST EXPENDITURE
£bn
CAGR
2.7%
• The 2010 Spending Review set out HM Treasury
plans on health spending for this Parliament
• In the last two years, the Coalition government has
stuck to the plan. There has been an increase in
spending in cash terms of about 2-3% pa. This is
obviously far below the 6-10% annual growth NHS
England had become accustomed to up to 2010.
• Once the impact of social care funding within the NHS
settlement is taken out, though, the growth is smaller
• For practical purposes, we are assuming a flat NHS
budget for the next five years
109.8
106.9
104.0
101.5
98.7
Social care
funding within the
NHS settlement
SUMMARY
• Why you should pay attention: Career planning matters!
• Making lateral transitions in medicine is more difficult than in other professions
• Case study: cardiothoracic surgery
• Economics are not on your side
• Medical school admissions have doubled
• The number of consultants has also almost doubled
• …during a period of big increases in NHS spending
• But the years of expansion are over, and NHS spending is likely to be flat for many years
• A shift in the nature of medicine
• Greater workload in managing long term conditions such as diabetes, heart disease, pulmonary disease
• The surgical specialities over-recruited in the past, leading to fewer NTN’s going forward
• While the demand for most types of surgery has increased due to an ageing and longer-living population, some
types of surgery have been replaced by newer surgical techniques or medical therapy
• Varicose veins
• Benign prostatic hyperplasia by transurethal resection (TURP)
• Gallstones
• General practice as a career
• Drivers for growth in general practice
• Demand for general practice
• General practitioners as small businessmen
• Partnership model in general practice
• Careers for doctors outside medicine
Surgical specialities over-recruited in the past, leading to fewer NTN’s going forward. The CfWI, which has analysed the
workforce, did not specifically look at the impact of technological change. Hence the demand shift away from surgery towards
medicine and general practice is likely to be more marked
Source: Centre for Workforce Intelligence – Shape of the Medical Workforce: Informing Speciality Training Numbers (2011)
EMERGING AND DECLINING SPECIALITIES
10
General Practice
Dermatology
Cardiothoracic surgery
Anaesthetics
Neurosurgery
Gastroenterology
Respiratory Medicine
Obstetrics and
Gynaecology
Trauma and
Orthopaedic Surgery
General Surgery
Paediatric Surgery
Otolaryngology
Renal
Medicine
* National Training Numbers
• Increase required to support shift from secondary to
primary care
• Incorrect expectation GPs with special interests would
take work from dermatologists.
• Strong growth in medium term expected to exceed
demand. Numbers linked to surgical demand
• Current neurosurgical workforce is young and does
not need imminent replacement
• Current growth of consultant positions (6.9%) not expected
to continue. Preventing oversupply risk
• Supply expected to meet demand by 2018, though
conflicting data mitigate robust analysis
• Reduction recommended to correct impending ‘bulge’
on qualified consultants in 2014
• Oversupply predicted in near future, as rate of growth
has outstripped population growth
• Oversupply predicted. Areas (e.g. breast) growing,
others (e.g. vascular) only maintaining intake
• While there is a current shortage of consultant paediatric
surgeons, there are currently too many in training
• No information available
• Oversupply already exists: many newly qualified
consultants are waiting over 2 years for positions
• After glut of trainees seeking consultant jobs in mid
2000’s, retirements match qualifying trainees
2,800
42
370
17
95
124
200
146
158
13
45
57
12
NTNs*
(2011)
3,250
48
354
16
89
114
160
116
123
10
33
32
12
NTNs*
(2014)
-43.9%
Over the past decade, the treatment of varicose veins by general surgeons has given way to injection scleropathy and
endovenous transluminal procedures
Source: Hospital Episode Statistics – Main Procedures and Interventions (3 Character) 2000/01 – 2010/11
TREATMENT FOR VARICOSE VEINS
Number of finished consultant episodes, 2000 - 2010
11
Total number of treatments
Conventional Surgery
Injection Scleropathy
Transluminal Procedures
• Varicose veins are a common medical
problem, and a frequent cause for
referral and treatment within the NHS.
They are one of the most commonly
performed operations by general
surgeons in the UK
• Several treatment options exist, with a
range of minimally invasive techniques
increasingly available
• Over the past decade, there has been a
sharp decline in traditional surgical
techniques in favour of injection
scleropathy and endovenous
transluminal procedures
• Proponents of minimally invasive
procedures cite advantages including
reduced post-operative complications,
faster recovery, and improved quality of
life
• Injection scleropathy can be performed
by a nurse, and therefore reduces the
requirement for general surgeons
In the 1990s, transurethral resection of the prostate was the gold standard of treatment for prostatic hyperplasia. Medical
treatment, however, has greatly diminished the demand for TURPs
Source: Long et al, Impact of pharmacotherapy on the incidence of TURP for BPH, Irish Medical Journal (2012)
TREATMENT OF BENIGN PROSTATIC HYPERPLASIA, IRELAND, 1995-2008
12
• In this retrospective study over a 14 year
period, national figures for transurethal
resections of the prostate (TURPs) were
obtained from public funding bodies.
(The figures do not include privately
funded procedures).
• There is a strong, significant correlation
between the 50% drop in TURPs
between 1995 and 2005 and the
increased use of medical therapies for
benign prostatic hypertrophy (BPH)
• As TURPs are for a trainee a “gateway”
to more difficult endoscopic procedures
such as bladder resections, the reduction
in training opportunities causes concern
to the authors
It is plausible that medical advances will reduce the requirement for cholecystectomies, one of the most commonly performed
operations be general surgeons. Preventative and litholytic drugs could radically alter the treatment pathway for gallstones.
Source: World Journal of Gastrointestinal Pharmacology and Therapeutics: Therapy of gallstone disease: What it was, what it is, what it will be
TREATMENT PATHWAYS FOR GALLSTONES
13
Symptomatic patient with gallstones
Consider
medical and
surgical options
Complicated
Non
complicated
Laproscopic
Cholecystectomy
Expectant
management
Oral Litholysis
Novel
treatments
Elective
• Cholecystectomies are one of the most
commonly performed operations in the
UK, with almost 64,000 performed in
2010/11 in England. They are
considered the gold standard treatment
of symptomatic gallstones.
• Gall-stones composed predominantly of
cholesterol which are calcium free may
be ‘dissolved’ by litholysis with UDCA*
or TUDCA**. However, only a minority
of patients (<10%) are amenable to oral
dissolution therapy
• Novel treatments for gallstones include
statins, and agonists and antagonists of
nuclear receptors involved in biliary lipid
secretion. It is possible that further
development in medical therapy will
further reduce the need for
cholecystectomies
* Ursodeoxycholic acid
** Tauroursodeoxycholic acid
SUMMARY
• Why you should pay attention: Career planning matters!
• Making lateral transitions in medicine is more difficult than in other professions
• Case study: cardiothoracic surgery
• Economics are not on your side
• Medical school admissions have doubled
• The number of consultants has also almost doubled
• …during a period of big increases in NHS spending
• But the years of expansion are over, and NHS spending is likely to be flat for many years
• A shift in the nature of medicine
• Greater workload in managing long term conditions such as diabetes, heart disease, pulmonary disease
• The surgical specialities over-recruited in the past, leading to fewer NTN’s going forward
• While the demand for most types of surgery has increased due to an ageing and longer-living population, some
types of surgery have been replaced by newer surgical techniques or medical therapy
• Varicose veins
• Benign prostatic hyperplasia by transurethal resection (TURP)
• Gallstones
• General practice as a career
• Drivers for growth in general practice
• Demand for general practice
• General practitioners as small businessmen
• Partnership model in general practice
• Careers for doctors outside medicine
A number of demographic, political and sociological factors are driving the growth of general practice
Source: CfWI – General Practice Summary Sheet; ONS population projections (2010 estiamtes) - England
DRIVERS FOR GROWTH IN GENERAL PRACTICE
15
Agenda to move care
into community
Increased
commissioning role
Age of General
Practice trainees
Ageing Population
Driver Comments
• The UK hosts an increasingly
elderly population
• By 2020, the number of
individuals over 80 will have
increased by 25%, and will have
doubled by 2035
• Over 80s have by far the highest number of
consultations per patient per year. The
increasing age of the population will drive
demand for general practice services
• Government policy stipulates that
care should be provided in a
community rather than a hospital
setting
• The 2010 government white
paper ‘Equity and excellence –
Liberating the NHS’ outlined
plans for for commissioning of
services to be carried out by GPs
• Individuals applying to train for
general practice tend to be older
than those applying for other
medical or surgical specialities
• The Royal College of General Practitioners
believes that most problems can be managed
in primary care, with acute referral as needed
• Community care is comprehensive, manages
cost, and frees up acute providers for serious
and specialist work
• An increase in the amount of time spent by
GPs commissioning services will reduce time
spent with patients
• In order to maintain services, there will have to
be an increase in the number of GPs
• GPs have often commenced or completed
training in another speciality before training as
a GP
• As a result, the working life of a GP will be
shorter than for other specialities,
necessitating a higher number of training
places to maintain numbers
General practitioners hold privileged position as independent operators within a highly regulated market which prevents entry
by others. They currently are able to generate profits and keep surpluses, whilst having an NHS pension.
Source: Laing & Buisson Healthcare Market Review (2011-12)
SIMILARITIES BETWEEN GENERAL PRACTICE AND PRIVATE ENTERPRISE
16
Similarities to private sector
GPs are regarded as independent contractors.
They compete for contracts, hire members of
staff within their practice, and draw their salary
from income provided by PCT contracts
GPs have a public sector pension entitlement.
This is a significant barrier to entry to ‘non-NHS’
practices
The health and social care bill suggests that in
future, contracts will be open to any willing
provider of care
General medical services and personal medical
services contracts are only open to GPs, as part
of the ‘NHS-family’
It is illegal for GPs to sell the goodwill of their
practice when they retire
Similarities to pubic sector
Contractual
Elements
Market
Elements GPs not allowed to exceed practice boundaries,
preventing growth of entrepreneurial GPs
Patients will have “the right choose to register
with any GP practice with an open list,”
suggesting a relaxation of current rules
Market strictly regulated by PCTs, which have
discretionary powers to pay or withold important
revenue streams
It is possible that NHS commissioning boards will
open the market more, reducing barriers to entry
for private GPs
Changes suggested by Health
and Social Care Act
• General Practitioners receive an NHS pension but are not salaried NHS employees. They are independently contracted by
PCTs, and manage their own practice, essentially operating as private enterprises
• GPs businesses are protected as the market is highly regulated, deterring entry from ‘non-NHS family’ operators. The Health
and Social Care Act will likely open the market more to private sector practitioners, though the extent that this will occur is still
unclear
The number of non-Partner GPs have doubled in the last six years, as existing GP Partners have been reluctant to appoint
new Partners
Source: NHS IC – NHS Staff 2001 – 2011 Overview
GROWTH IN THE MEDICAL WORKFORCE
Number of staff (Full Time Equivalents)
17
92,910
102,344
114,470
121,264
132,683
134,713
Consultants
GP Providers
(Partners)
GP Registrars,
Retainers and
Others
Doctors in Training
Other medical
workers
• Since the 2005 GMS contract
which allowed GP Partnerships to
keep and distribute their year end
surpluses, there has been a big
rise in the number of non-Partner
GPs
• On partner retirement, existing
partners have been employing
salaried GPs rather than sharing
the fruits of Partnership with new
GPs
• We believe that over time, GP
Partnerships will come to
resemble other professional
services partnerships, with a
“pyramid” structure
CAGR
3.8%
Over time, it is likely that General Practice will come to resemble other professional services firms, with a career structure culminating in
Partnership
Source:LEK.com, websites
CAREER STRUCTURES IN OTHER PROFESSIONAL SERVICE FIRMS
18
Consulting firm Accounting firm
• Other professional services firms have a “pyramid” career structure, with numerous juniors (who are paid a fixed
salary + bonus in good years) and a smaller number of Partners (who divide the annual profits of the firm amongst
themselves)
• The firms with the highest earning partners are those with numerous juniors per partner (eg. accounting firms where
the ratio might be 10:1). In top strategy consulting firms and top law firms, the ratio is much lower, perhaps 3:1.
• In other countries (eg USA, Australia) this kind of structure is common, and doctors need to buy out retiring partners.
In the UK, it has been illegal to sell the “goodwill” of a practice since the inception of the NHS in 1948
SUMMARY
• Why you should pay attention: Career planning matters!
• Making lateral transitions in medicine is more difficult than in other professions
• Case study: cardiothoracic surgery
• Economics are not on your side
• Medical school admissions have doubled
• The number of consultants has also almost doubled
• …during a period of big increases in NHS spending
• But the years of expansion are over, and NHS spending is likely to be flat for many years
• A shift in the nature of medicine
• Greater workload in managing long term conditions such as diabetes, heart disease, pulmonary disease
• The surgical specialities over-recruited in the past, leading to fewer NTN’s going forward
• While the demand for most types of surgery has increased due to an ageing and longer-living population, some
types of surgery have been replaced by newer surgical techniques or medical therapy
• Varicose veins
• Benign prostatic hyperplasia by transurethal resection (TURP)
• Gallstones
• General practice as a career
• Drivers for growth in general practice
• Demand for general practice
• General practitioners as small businessmen
• Partnership model in general practice
• Careers for doctors outside medicine – not really the focus of this talk, come and see me later !
CONTACT
20
Dr Victor Chua MB BChir
Partner
Mansfield Advisors LLP
St John's Building
79 Marsham Street
London SW1P 4SB
UK
Mobile: +44 7768 003 821
victor.chua@mansfieldadvisors.com
See Twitter for occasional articles on
UK healthcare:
https://twitter.com/VictorChuaUK
Dr Chua is willing to be contacted for
careers advice / mentorship