Desflurane, workforce and morality

When I was Clinical Director for Theatres, I had three priorities: safety, workforce and finance (in that order). The use of desflurane fell into the latter area as it was eight times more expensive than isoflurane, and consumption was steadily increasing. This bothered our business partner (a.k.a. departmental accountant) a lot. From the insulated safety of my spreadsheets, I couldn’t see an increase in throughput nor any reduction in adverse events or an increase in quality, so I petitioned the department to reduce the use of desflurane to the small number of cases where it made a difference. I made the argument that if we saved cash, we could afford more kit and colleagues and improve patient care. That argument cut no ice, so I moved desflurane into the drug cupboards and colleagues had to make an effort to get their hands on it. However, it soon became apparent that unless I was going to stand outside the many drug cupboards and personally ‘Paddington Bear-stare’ at anyone who wanted it, that manoeuvre wouldn’t work. The answer to this problem came in the form of the ecological impact of desflurane. The use of desflurane is associated with a very large carbon footprint, so anyone using the agent was essentially punching puffins and putting two fingers up to the many nations suffering the impact of climate change. This moral argument pushed the right buttons with my middleclass colleagues. and the spiralling use of desflurane slowed.

The lesson of finding the right argument to make change is relevant elsewhere. Currently, we face a significant workforce crisis. The pre-COVID 2020 RCoA workforce census showed that in the UK there were 680 unfilled consultant posts and 243 unfilled SAS posts [1]. Clinical Directors also reported that they had enough additional work for another 374 consultants and 113 SAS doctors. They estimated that over the next two years they would need another 1104 anaesthetists, so in two years' time we would need to employ almost 2000 more anaesthetists. Where would these doctors come from? The RCoA reported that they expected 700 new CCT -holding anaesthetists to come out of training in that time. This would help, but won’t fill even half the gap. An increase in medical students or anaesthesia training places, while welcome, won’t increase our capacity for another 5-10 years. Our pipeline supply is inadequate, and we can’t increase it anywhere near rapidly enough. With this in mind, I and others have argued for some time that we need to change our model of anaesthesia delivery and expand our use of Anaesthesia Associates who can be trained and functional in two years. However, this requires a cultural and organisational change, and the fact that only 1% of our workforce are Anaesthesia Associates suggests there’s little enthusiasm.

We can’t increase trainee numbers quickly and there are ethical issues around overseas recruitment. We need a new model.

It's sometimes useful to look back. A rapid increase in the size of the UK anaesthesia workforce has been seen before. If we look at data from successive RCoA censuses (Table 1), we see a dramatic rise in the number of anaesthetists between 2003 and 2007 [2-5]. Much of this increase occurred because of an expansion in consultant numbers from 4921 to 6233. The driver for this change was the 2003 consultant contract, which moved consultants from a professional session-based to a time-based contract. Hours of work were limited by the European Working Time Directive and the mean number of hours worked by consultants fell by 1.5 hr per week. This may not seem dramatic, but in an average sized department it required at least one more consultant colleague. Replicate that across the country and many more consultants were needed. Thankfully, an expansion of the healthcare workforce was a key initiative of the government at the time so funds were provided to make the necessary investment in additional staff. Clearly, the pipeline supply of anaesthesia trainees to fill those consultant posts couldn’t be ramped up quickly, so doctors were sourced from overseas. GMC data shows a spike in international graduates registering with the GMC around this time (Figure 1). Nothing lasts forever, and by 2006 the government’s position had shifted, policies on international recruitment were tightened, and work permit numbers reduced. However, in that period the import of doctors had significantly helped our workforce crisis. Could we or should we, use the international workforce resource again? What impact might that have on those countries?

Figure 1. New first time registrants to GMC 2000-11 (date from GMC February 2022). IMG - international medical graduate; EEA - European Economic Area

In 2017, the World Federation of Societies of Anaesthesiology (WFSA) published a global survey of the anaesthesia workforce [6]. The survey was performed in 2015-16 by collecting data from membership organisations, anaesthesiologists attending international conferences, and by contacting anaesthesia providers in non-WFSA member countries. This data enabled the authors to calculate the number of anaesthesia providers per 100,000 population in 194 WHO member states. The data make unsettling reading. Much of sub-Saharan Africa, Afghanistan, and Indonesia have less than one anaesthesia provider per 100,000 population; India and Pakistan have less than two and South Africa has three anaesthesia providers per 100,00 population. At the other end of the spectrum, Austria has 39, Denmark has 34, Germany has 31 anaesthesia providers per 100,000 population. France and Spain both have 16, Ireland 18, Iceland 20, and Italy has 26 anaesthesia providers per 100,000 population. The USA has 21 anaesthesia providers per 100,000 population. In this dataset, the UK lies around the middle of the well-resourced European pack with 18, which is broadly the same as that derived from the censuses. These data include countries from which the UK has historically sourced additional doctors, such as India and Pakistan. How comfortable can we be extracting the only anaesthesia provider for almost 100,000 patients? Surely this can’t be ethical?

Table 1. Number of anaesthesia providers per head of population TABLE

So, we have a significant workforce gap that is likely to be felt increasingly acutely as we tackle the backlog of patients whose treatment has been delayed by the pandemic. We can’t increase trainee numbers quickly and there are ethical issues around overseas recruitment. We need a new model. It’s no surprise that Health Education England are planning to ramp up the number of training places for Anaesthesia Associates, but for this to succeed we need the specialty of anaesthesia to set a new course. We need departments to plan how they would incorporate training places for Anaesthesia Associates alongside our medical anaesthesia trainees. They need to devise sustainable, safe and interesting jobs for this group of healthcare professionals and ensure they feel welcomed and supported. Perhaps the moral argument around protecting the overseas workforce may persuade colleagues that they need to invest in Anaesthesia Associates, embrace this change and help save the planet.

Hamish McLure
Consultant Anaesthetist & Medical Director (Professional Standards & Workforce Development)
Leeds Teaching Hospitals NHS Trust

Twitter: @HamishMclure

References 

1. Royal College of Anaesthetists. Medical Workforce Census Report 2020, 2020. https://rcoa.ac.uk/training-careers/working-anaesthesia/workforce-planning/medical-workforce-census-report-2020 (accessed 21/2/2022). 
2. Royal College of Anaesthetists. Royal College of Anaesthetists Census Report 2003, 2003. https://rcoa.ac.uk/sites/default/files/documents/2019-08/ RCoA%20Census%20Report%202003.pdf (accessed 21/2/2022). 
3. Royal College of Anaesthetists. Royal College of Anaesthetists Census Report 2007, 2007. https://rcoa.ac.uk/sites/default/files/documents/2019-08/ RCoA%20Census%202007%20Report.pdf (accessed 21/2/2022). 
4. Royal College of Anaesthetists. RCoA Census 2010, 2010. https://rcoa.ac.uk/ sites/default/files/documents/2019-08/RCoA%20Census%202010%20Results. pdf (accessed 21/2/2022). 
5. Royal College of Anaesthetists. Medical Workforce Census Report 2015, 2016. https://rcoa.ac.uk/sites/default/files/documents/2019-09/CENSUSREPORT-2015.pdf (accessed 21/2/2022). 
6. World Federation of Societies of Anaesthesiology. World anaesthesiology workforce map, 2021. https://wfsahq.org/resources/workforce-map/ (accessed 21/2/2022).

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