Planning the medical workforce: struggling out of the time warp

Over the last 50 years there has been a regular cycle of Government committees which have forecast “shortages” and “surpluses” in medical manpower. It is remarkable how little change there has been in the methods used in these forecasts. This has occurred despite regular critiques of the forecasts and their methods. Why is this work apparently trapped in a “time warp” of analytical and research paralysis? In 1944 the Goodenough Committee advocated a modest increase in the number to be trained as doctors. The Government was more enthusiastic, increased the supply of doctors and precipitated an apparent surplus which the WIllink Committee (1957) proposed to remedy by reducing entry to medical schools. The Todd Royal Commission (1968) identified an impending major shortage and intake was dramatically increased. All these studies were criticised in the 1960s because of the failure to, for instance, explore the implications of alternative skill-mixes and incentives. Such analysis requires the examination of all inputs, not just doctors, used to produce health care and health and how market incentives (pay and prices) affect their behaviour. Whilst this advice was ignored, the forecasters began to improve in other ways. The forecasters began to pay more regard to budget constraints and carried out their work at intervals of a few years rather than once a decade. Finally in 1992 a Standing Committee (Medical Manpower Standing Advisory Committee) replaced the system of ad hoc committees which had previously been charged with the task of forecasting. However, the failure to address skill mix and incentive issues has resulted in a 1992 doctor manpower forecast that is flawed and potentially mischievous. There are major variations in clinical practice and most interventions have no scientific basis. The inherent acceptance of such practices and existing staffing arrangements in these forecasts is inefficient. There are major changes taking place in skill mix (e.g. increased use of practice nurses in general practice) which, if efficiency and widely adopted, could translate the apparent shortage of doctors forecast to emerge by 2000 into a surplus! The authors argue that the 1992 forecast could be improved by sensitivity analysis (e.g. for GP/population ratios). They conclude that unless the issues of scope (forecasting for all health care staff not just for doctors alone), skill mix and incentives identified in the 1960s are addressed effectively, the recommendations of the Standing Advisory Committee may produce the doctor “surpluses” of the early twenty-first century. The analysis paralysis inherent in the conservative activity of existing manpower planners should be challenged at the level of principle and practice, and this implies that the research activity proposed in the 1960s is carried out in the 1990s to facilitate efficient planning in the twenty-first century.