The government’s idea of compelling doctors to work for a period in the NHS…

The general public regards the NHS as something between a ‘sacred cow’ and a ‘national treasure’, despite all the pressures that it is under. For decades it has provided a universal service, largely free* at the point of use. The public may have a collective memory of the abysmal provision before it was introduced; to see just what changes it made, you have to look for ‘the short and simple annals of the poor’ — you could start by reading this man’s memoirs of the Great Depression. His sister died of TB because the family were too poor to afford any treatment for her. The first NHS financial crisis came within months of starting in July 1948. It was assumed, with charming naivety, that the improved health of the population would lead to a reduction in the need for services. The extent of the poor health of the general population simply wasn’t appreciated — and it wasn’t appreciated because the mandarins of Whitehall ’knew better’.  (Strictly, when first established, the label ‘National Health Service’ referred to the system in England and Wales; both Scotland and N Ireland had very similar systems with slightly different names; these remain separate.)

Surprisingly perhaps, the introduction of the NHS wasn’t an easy birth. Many medics felt that they would become little more than salaried employees of the government, obliged to do whatever the political masters demanded. Consultants were won over, it seems, by ‘having their mouths stuffed with gold’. Certainly, in the first decades of the NHS, doctors were largely free to practice medicine as they felt fit; administrators were there to facilitate them. From the 1980s, ‘managerialism’ was the theme with demands, targets, goals, outcomes and all the impedimenta of such organisation becoming de rigeuer.

The NHS in England has recently become concerned with the numbers and retention of medical staff in the system. They issued a consultation paper (here and here) with a couple of suggestions. Firstly, there are ideas for increasing the numbers of medical students. Secondly, they raise the idea that newly qualified doctors should be obliged to work for the NHS for several years — 5 years seems to be the most favoured option. To support this case, they say that the cost of training a medical student is £230,000 (discussed here). This approach was suggested at least once in the past, but rejected. What they don’t do is to directly address the question of why so many doctors are leaving the NHS, often continuing their career abroad, or why so many doctors are so disenchanted with their work

The number of medical students is set by the NHS (or various committees on their behalf) as a form of numerus clausus. It takes between 10 and 15 years or so from entry as a medical student to becoming a specialist. Clearly, seeing so far ahead is problematic. Further, while medicine was once a male-dominated profession, today rather more than half of medical students are female; society has moved on from the pattern of a male breadwinner with a female home maker, even if most child care is still done by women. There is also the modern idea of a ‘life/work’ balance.

Nonetheless, the idea of compelling doctors to work for five years in the NHS is totally disgusting, even if 91% of respondents in a survey thought it a good thing; they presumably thought that there was a ‘moral obligation’ on doctors to repay the costs of their training. They clearly don’t see that this coercion is only possible because of one very specific condition.

Think of other students at university. Law students aren’t obliged to become government lawyers for several years; given the ‘austerity’ reductions in legal aid, a cohort of cheap lawyers could be very useful. And the government has little use for graduates in ancient languages such as Latin or Greek. (And as the government has no use for such graduates, so the total costs of their university education are not available.)  Such students go to university for education, a rigorous academic process involving critical thinking, to learn the theory. They aren’t trained at university; law graduates must attach themselves to solicitors or barristers for training. Classical graduates demonstrate that they have brains which can be trained — unsurprisingly, they make very good traders in financial markets.  Medics, architects, veterinary surgeons, engineers, teachers and even seminarians have a mixture of education and training in their colleges. Lest you accuse me of being elitist, skilled trades people also have education, training and practical experience in their colleges.

So how can the government expect that they can force — coerce — doctors to work for the NHS? It’s very simple; the NHS is a monopoly employer. It’s not possible to undergo post-graduate training in medicine in the UK anywhere other than in the NHS: there is no parallel system of public and private provision as there is in other countries. (There are some private hospitals, but they don’t offer the complete range of services that can be expected in an NHS hospital.) Once, up until around 1950, medical students could leave with their degree and go directly into practice. Subsequently, the newly qualified have been required to do a period of obligatory training in hospital before they can be fully registered by the General Medical Council. And this isn’t enough today to become a recognised specialist, something that takes years of further training, mostly but not exclusively in hospitals. The NHS employs almost all UK medical graduates; only a small number work entirely outside the system, in pure private practice, in pure research or for pharmacological firms. A tiny number overall ‘escape’ into other areas, often the arts. The Cambridge Illustrated Companion to Medicine has an incomplete and outdated article on truants’, here. Dr Leo Varadkar, the candidate most spoken of as the next leader of Fine Gael, and thus the next Taoiseach (Prime Minister) of Éire, is a medical graduate, having studied at Trinity College.

Although N Ireland produced ‘surplus’ medical graduates in the past, there is now an overall shortage, not just here but throughout the UK. You will have read of the closure of rural practices in Fermanagh and elsewhere as the GPs retire and there are no replacements. (And such a wave of retirements always seems to come as a surprise to the planners.) I’m sure you have seen stories of junior doctors working a series of 12-hour shifts without a break. HGV drivers must have rest breaks — to ensure this, there are tachographs in the cabs. Airline pilots aren’t allowed to work such long shifts without a break. Even in the 1930s, the non-stop LNER ‘Flying Scotsman’ service between King’s Cross and Waverley had a second crew in a front compartment who, using a narrow passageway in the tender, could replace the initial driver and fireman on the footplate at the halfway point.

Doctors have further concerns and problems; a lack of doctors means that rotas either go unfilled, or are filled — at considerable extra expense — by locums of variable quality. Inadequate staffing can only increase pressures on those working; and for many there is an increasing feeling that they are only a small cog in the machine whose operators care little for them. Job satisfaction is in decline. Remember the junior doctors’ strikes last year? They came about because of a new contract, one which the Secretary of State was eventually able to impose. Is the imposition of a contract to further a political ideal really the best way to generate goodwill? Added to all this is the neo-liberal ideologically driven agenda of ’austerity’ and the ’need’ to extract £22 billion from the NHS by way of ‘efficiency savings’, frequent structural changes and ‘creeping privatisation’.

Any sensible employer would recognise that the inability to retain staff points to problems with employment; and any sensible employer would ask what those problems were, and then seek to address them. An employer that seeks to coerce its workers into contracts binding them for a period of years would rapidly find itself without staff were alternative employment opportunities available. In this case, the government, those who organise things on our behalf for the common weal, are abusing their monopoly power in a way that is wholly morally repugnant. This is force majeure.

Apart from the respondents to the survey, this repugnant idea seems to have generated little public attention; perhaps Brexit and the forthcoming election have drowned it out. You can read more on Stella Vig’s blog and on her article for the British Medical Journal (here and here). And she works for the NHS in England, whereas I’m superannuated and rant from the sidelines.

*Free: the cost of the NHS is met from taxation. ‘Free at the point of service’ is taken to mean that you don’t have to show your credit card before any treatment.

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  • hgreen

    If the state pays for the training of doctors (via zero tuition fees) then doctors should have to work for the NHS for a set period of time. However we currently have the situation where student doctors have to pay their own fees, graduate doctors should thus be free to work where they want.

    The crisis in doctor numbers seems to be not an issue of salary but of work life balance.

  • Old Mortality

    The long-term viability of the NHS in its current form, depends on its ability to employ enough people whose principal motivation is not maximisation of income or other terms of employment (maternity leave being an example). Unfortunately, there appear to be fewer and fewer doctors in this category, even in NI which has relatively small private health provision and a strong ‘stay-at-home-with-mammy’ element who are not going to disappear for very long.

  • Old Mortality

    They’re not paying anything like £230,000 though, are they? Perhaps a multi-tiered approach should be adopted with at one extreme a complete exemption from fees in return for a minimum number of years in the NHS and at the other end paying full cost in return for no NHS obligation.
    I think you would find a lot of resistance if you reduced hours but froze salaries.

  • Jag

    The shortage of doctors in the NHS will be comprehensively and finally solved when SF get their way and impose a salary cap of £100,000 a year on doctors.

    Sadly, SF neglect to say they’ll have to impose Cuba-like border controls to stop the exodus of doctors to better-paying countries.

    Vote SF!

  • Jag

    Aside from Cuba, one of the best countries for the provision of medical care was, in my experience, Syria. Before the civil war obviously. There were doctors offices on most streets in Damascus. What was their secret? As far as I could tell, lower barriers to training to become a doctor, lower tuition fees, lower standards for qualification, easier to set up as a GP.

  • Vince

    A number of changes are needed. The current system is not working and the situation regarding retention of staff has been at a critical point for some time now. This is particularly true of medical specialties such as the one I have experience of.

    After Foundation Training (the first 2 years after qualification) an exodus has been occurring over the past 5 years. Some choose to work for locum agencies. The remuneration is greater and they feel there is more flexibility and have more capacity to pay off student debts. The paradox here is that they can end up working along colleagues at the same level in an official training post but who are earning less for the same work. A few work for private sector companies (sometimes referred to as “independent sector”). A larger number go off to Australia/New Zealand etc for a year or two for lifestyle reasons. Many of these will come back but a few are lost forever. This loss of trainees is having a day-day impact on patient care and safety. It is also making workforce planning increasingly difficult.

    Personally, I feel that there is an obligation upon graduates to “give something back”. The NHS has trained and educated them to a generally very high standard. The cost of this far exceeds the fees paid. Having said that, removing student fees entirely would eliminate that as an excuse. Together with the elimination of fees, I
    would take enrolment at a UK medical school as being linked with a statutory commitment to spend at least the first 5 years after graduation working within the NHS. Clearly there would have to be exceptions allowing for health/pregnancy etc but such a move would stabilise the workforce situation, ensure that taxpayers got a return on their investment and remove the issue of fees as a deterrent to entering medical school.

  • hgreen

    I said nothing about freezing salaries. Reduction in hours however is a change that will improve recruitment and retention.

  • Old Mortality

    Vince
    ‘Some choose to work for locum agencies. The remuneration is greater and they feel there is more flexibility and have more capacity to pay off student debts.’
    I’m genuinely puzzled as to how there is scope for agencies to operate in a place like NI where the independent sector is comparatively small. Why can’t the NHS use its monopsony power to squeeze out the agencies and force down remuneration for temporary staff? Can you enlighten me?

  • murdockp

    ‘he idea of compelling doctors to work for five years in the NHS is totally disgusting.

    My god what a statement. My response would be pay for your own training in its entirety say £500k then not a day does the BHS require from you. If the government pays for a substantial part of your training then you have obligations to stay which is only fair.

    Your skewed article mentions lawyers not obliged to work for government but fails to mention military personel in every country on earth who after expensive training must serve for a much as then years

    In the US many choose doctor train g via the military as the training is free but you must serve seven years.

    In the UK and RAF pilot must serve six years.

    Doctors including students have a sense of entitlement not seen in any other profession. They strike about terms and conditions for jobs they do not even have and in the knowledge of the T&C’S in advance of their career choice and still the loan.

    I have little sympathy for doctors.

  • Old Mortality

    Lowering academic admission criteria could be part of the solution here. Do you really need to have 3As in order to be a bog-standard GP, especially when so much support is available from IT. We don’t call our GP Dr Google for nothing.

  • chrisjones2

    What you are all describing is the outworking of a monopoly or oligoipoly.

    We import huge numbers of Doctors from abroad because we do not train enough. As in any profession allowing the BMA to regulate the numbers allows them to restrict the service and push up wages. This must stop.

    The issue of Doctors getting trained here then leaving for the US or Australia is also a problem ….so lets increase the student fees to economic levels then if they want to go they can but we can pursue them for the debt.

    We should increase training places by say 40% and direct that management of Training should be taken over by the NHS. The BMA can play a key role in setting standards . Its disciplinary role should also go to a separate body leaving it as what it wants to be – a union.

    As part of the planned renegotiation of Contracts recently qualified Doctors can be offered a significant retention bonus after a certain number of years service which can help pay off their (even larger) student loans. This can be set by the NHS to reflect the demand in certain areas eg its hard to get staff in geriatrics and A&E (which offer less scope for private work) so give them an even larger bonus after say 5 years work. I personally would support a bonus large enough to completely eliminate the student loan after say 20 years NHS service. A transitional scheme could allow Doctors with existing loans to migrate into this new system giving them an immediate incentive to remain. This could also be tweaked to support male or female Doctors who want to take career breaks to raise children then return to the profession.

  • chrisjones2

    Yes …Dictatorships are often very good at these things ….as well as murdering dissidents and gassing their populations

  • Granni Trixie

    Exodus to south of the border?

  • Granni Trixie

    Surely the crisis is yet another example of lack of forward planning in Stormont?

  • Korhomme

    The BMA (British Medical Association) is a trades union. It may be consulted on student numbers, but it does not set them — the NHS and the government sets student numbers.

    The GMC (General Medical Council) is the licencing and regulatory body. It sets general standards of behaviour. It does not set student numbers.

    The medical Royal Colleges set the standards for post-graduate training, and run examinations and teaching courses.

    I understand that the ‘average’ student has a debt of around £65,000 at graduation (tuition fees and living costs). How do you legally pursue someone abroad in a foreign jurisdiction?

  • Korhomme

    The Armed Forces in the UK offer students the chance to sign up and have their fees paid and to receive a (smallish) salary. This isn’t a popular choice; people perhaps think that their prospects of advancement when they return to civilian life will be diminished.

    Only medical graduates, it is suggested, will be required to work for the government (through the NHS). Why is this not discriminatory? Why not all graduates?

  • Korhomme

    There are some ‘full time’ locum GPs. Mostly, though, locums are recruited from those in full-time employment. Often, but not inevitably, they will work for a neighbouring Trust rather than in their own place of employment, and in a very similar job. That at least reassures the agencies and the employers that the prospective locum is reasonably qualified and competent.

    In part, this problem arises because under EU regulations an employer cannot require an employee to work more than 48 hours in a week (averaged out over several weeks). An employer and an employee may agree to work more than 48 hours, but the employee can refuse. Once we have the ‘joy of Brexit’ we might expect a return to 80 hour weeks for doctors as the norm.

  • Korhomme

    Personally, I feel that there is an obligation upon graduates to “give something back”.

    Would you then extend this to all graduates? If not, why not?

    For locums, see my response to Old Mortality.

  • Korhomme

    I don’t follow the logic; why will a cap on earnings solve a recruitment/retention problem? (Or is this irony?)

  • Croiteir

    Sarcasm I think, to me he is saying that the solution of capping pay will only lead to greater shortages as people will depart for jobs in other places/countries which offer higher wages

  • Korhomme

    Management theorists say that income is not a motivator, rather it is a ‘hygiene factor’ — that is, you expect to be paid for what you do. Increasing this may not bring about similar increases in output. (This is very apparent in the pay of chief executives; where in the 1980s, it was about 40 times average earnings, today it is 200 – 400 times; but there hasn’t been a corresponding improvement in the turnover and profits of the companies.)

  • Korhomme

    The reduction in hours has however been associated with a very considerable increase in the intensity of work. Partly this may be because there are simply less doctors to go around; partly it is because medicine today is so much more complex than it used to be.

  • Korhomme

    I did read that about 10% of doctors in NI are from the EU, though I’m
    not sure of the split between hospital and general practice. (This is apparently a higher percentage than in GB.) It has been
    easier to recruit from the EU than from the subcontinent in recent
    years. After Brexit, what then?

  • Korhomme

    There was a study, I think in the US, where a group who were unsuccessful at entry into a medical school were compared to those who were successful. The unsuccessful, IIRC, did get into a less prestigious medical school. And at the end of the day there was no difference in the abilities and copentencies between the two groups.

    It’s not just 3As; students also under go aptitude tests etc before they can gain entry to medical school.

  • chrisjones2

    You dont. You pursue them in the UK. There are then various ways of enforcing debt abroad. It depends on the state .

    At the moment in the EU this is very easy but that will change. In other countries its much harder but would a medical company in say Australia really trust a Doctor who had bailed out of the UK evading large unpaid debts? Would a licencing authority consider this a factor?

    The NHS or Student Loan Company could simply sell the debt to a third party debt contractor . The Doctor would then owe the money to them and they could pursue it eg in Australia.

    The other option is to just freeze the debt in the UK and if they return at any point they can be brought to court and made to pay up with interest.

  • Jag

    A weak attempt at humour on my part Korhomme. SF want to cap public sector salaries including in health. Given that £200k a year is considered slave wages these days in the medical profession, there would undoubtedly be an exodus, thereby compounding the problem with shortages.

  • aquifer

    “the idea of compelling doctors to work for five years in the NHS is totally disgusting”

    Not totally, and maybe three rather than five and with a break after Uni, but the terms of the offer would have to be clear when 18 year olds choose their university places.

    Doctors in this situation would presumably be guaranteed a job, unlike other graduates, and those terms could attract more of those for whom a career working in the NHS is seen as very worthwhile.

    The danger now is that we simply run out of doctors who are very expensive to train, and that this shortage will be used to justify some sorts of privatisations of services.

  • Jag

    It won’t solve the problem with shortages of course particularly beyond the GP level, but a recent initiative down South may help around the edges. Introducing the video GP in your local post office.

    http://www.thejournal.ie/post-office-gp-3367638-May2017/

  • Korhomme

    I didn’t realise or had forgotten that this limitation of salaries was an SF idea. Sadly, during my time in the NHS I was never paid anything approaching ‘slave wages’.

  • Korhomme

    There were (are?) private GP surgeries at British train stations, particularly in London, where you could ‘drop in’ for a quick consult. I’m not sure if they are still active.

    In remote places, the Scottish Highlands and Islands, there is an on-line service for some consultations; it seems particularly suited for the diagnosis of skin rashes and lesions.

  • El Daddy

    Great topic, but Prime Minister of Éire is bizarre. Would you call Merkel the Chancellor of Deutschland, or of Germany? Ireland’s name as a state is simply Ireland. If you need to differentiate from NI, say the Republic.

    Aside from that, I particularly agree that it would be unjust to force medical graduates to stay to work after finishing their degree. If graduates of other disciplines are free to do as they please, how is it fair to make it mandatory for medical graduates to stay?

  • Korhomme

    The Bunreacht says that the name of the country is Éire, or in the English language, Ireland; and that Irish is the national language, with English as an official but second language; and if there are clashes between the Irish and English versions of the Constitution, the Irish version will prevail. (The original drafting of the Constitution was, however, in English.)

  • Korhomme

    Medical graduates are de facto guaranteed a job somewhere in the UK for two years after graduation; two years’ work are necessary to become fully registered with the GMC.

  • Old Mortality

    Thanks, but it still doesn’t answer the question as to why the NHS is paying commission to agencies to employ people who probably already work for it. If you are correct that doctors are willing to ‘moonlight’ on their days off, it gives the lie to the notion that they are forced to work too many hours. Nurses, presumably are equally guilty.
    Are you suggesting that this is a convenient arrangement for both parties to circumvent EU regulations?

  • Old Mortality

    ‘…for whom a career working in the NHS is seen as very worthwhile.’
    As in providing a relatively well paid job for life, guaranteed by the state? I can see how that might appeal to a lot of people without a strong sense of vocation, particularly in NI where more lucrative occupations are less plentiful or secure.

  • El Daddy

    Aye, I’m aware of all that, but since the English language is the one that is in use as common parlance online, why deviate?

  • Korhomme

    I suspect that doctors who would volunteer for ‘overtime’ with their employer would get the standard rate of pay, or perhaps a bit better. By working for an agency they are likely to be paid considerably more. I’m not sure how many are keen on such locum work, preferring rather the time off. And the 48 hours is averaged over weeks, so the hours of employment can be erratic; it’s certainly to work for 12 hours a day for 7 days in a row, with ‘rest time’ subsequently.

    I guess it’s the same for nurses.

  • Korhomme

    No special reason, though I hope that there would be readers outside the island. The problem is actually with the NHS in England; it hasn’t been suggested in NI.

  • Old Mortality

    ‘It’s not just 3As; students also undergo aptitude tests etc before they can gain entry to medical school.’
    That’s reassuring but they still have to get their 3As. I’m also concerned that medicine is creaming off far more bright people than it needs. Perhaps there should be a fast-track as in the upper echelons of the civil service to provide the surgeons and consultants while others with lesser qualification are recruited for more routine practice.
    Alternatively, now that we are inflating nurses’ academic status, is it time to give them responsibilities that are currently undertaken by doctors exclusively?

  • Old Mortality

    If you read Korhomme’s reply to my earlier post, he seems to be suggesting that doctors already employed in the NHS are taking on additional hours as agency locums.
    Perhaps they want shorter hours so that they can have more time to do more lucrative agency work.

  • Korhomme

    I think you have a very valid point with the 3As; you need to be reasonably clever to do medicine, but you don’t need to be brilliant; there’s more to it than can be measured academically.

    Most medical students in the UK enter as undergraduates, and study for 5 years. There are some, not many, post-graduate entry courses; study there is 4 years. This might be a way to increase numbers — you may remember that such a medical school was suggested recently for Magee College.

    Fast track: surgery and much of internal medicine, cardiology and gastro-enterology, and radiology is based around manipulative skills, the use of implements. It’s been said that to get really good at such skills takes 10,000 hours of practice — the same whether you are a concert pianist or a surgeon. If this is correct, it makes fast track difficult.

    Nurses: yes, what you suggest is certainly realistic and possible. But it could become a sort of closed-shop trade union problem; both nurses and doctors can be very protective of what they see as their own areas.

  • Vince

    It doesn’t apply to all other graduates in the same way although it would apply to Physios, Social Work etc. Someone doing a politics degree doesn’t have to join a political party, nor will they have been trained by them. An economics graduate won’t have been trained by Ernst & Young. A medical graduate will however have been trained in NHS hospitals & therefore some obligation to work in the NHS is reasonable, rather than working as a mercenary elsewhere.

  • Vince

    The people doing the locums may be working ONLY for an agency.

  • Korhomme

    Physios and social workers are both educated in the theory and trained in the practice as students; and while training, they also treat or manage patients or clients. In a way, they are doing some work for the NHS for free. (In GB, social services are the responsibility of the local councils, not the NHS.)

    Lawyers and economists learn the theory at uni; the practice comes with their employment. So the employer gets people who have a grounding in the subject, but the employer doesn’t directly pay for this (though they do pay through taxation in general).

    Some students do sandwich courses; the third year is enhanced work experience for which they can expect some pay. Students doing, say engineering or chemistry will also need lots of sophisticated equipment, like medical students, in order to give them an introduction to training.

    Medical students do clinical studies in the second part of their course; they will provide some low-level care and treatment of patients. It’s not as if medical students do nothing; the limits to what they may do are regulated by the GMC — for only registered doctors may properly practice medicine.

    I don’t know where the figure of £230k comes from; and despite searching a couple of weeks ago, I could not find any reference to the total costs for any other student group.

    It’s only possible to achieve fully registered status with the GMC after two satisfactory years work; and this can only be done in NHS hospitals. Students, if they want to continue in medicine, are captive for two years. If they want to train as a specialist, and all fields are specialties today, must continue in the NHS if they stay in the UK; there are no alternatives.

    So then, why are so many young graduates so disenchanted with medicine that they want to leave after these two years (seven years in total)? Do you really think that forcing unwilling people to work for a further three years will be safe and effective?

  • Doctor M

    In NI, the HSC has tried to circumvent agencies by increasing their hourly rate (though it is still short of the agency rate) and by trying to force the use of their internal locum service.

    I no longer do agency locum shifts but have done in the past, even when the differential in the rate was small. Why? Because the agency treated me with respect and paid me within a week. If I had done the shifts as an internal locum payment would be up to two months away, if at all (the HSC has previously “lost” many of my locum forms).

    At the end of the day it’s a free market, and these shifts are being done as extra cover after already working >48 hours per week.

  • Doctor M

    It depends.

    Historically, employment for the first post graduate year was effectively guaranteed as graduates were still the responsibility of the medical school for that year and the medical school had a responsibility to ensure they had a training post to gain their full registration.

    That has all become quite muddy with the extension of foundation training to two years.

  • Vince

    The reality is that they are working, many of them within the NHS but just for locum agencies. The argument that they are disenchanted surely can’t apply to them? Some may well not like the NHS but the reality is that there is a vicious cycle at work – the more that drop out/opt out of training posts and the usual career pathways, the harder it gets for those who remain.

    There is the argument about paying off accumulated debt – as above, this would be substantially addressed by removing student tuition fees.

    Some have a desire to travel before “settling down”. Travel opportunities do however present themselves within higher specialist training – I am familiar with specialities where many trainees avail of this later in training, going elsewhere in the UK, Australasia, continental Europe and North America.

  • Vince

    Your final point is very pertinent.

  • Doctor M

    The commentary here slightly misrepresents the actual situation with regard to the costs of medical training.

    Undergraduate training happens part in medical school (university) and part in hospital / GP (NHS). The NHS is paid by the university for the teaching of the students. Yes, a large proportion is funded ultimately by the state but NHS trusts and GPS have their income augmented through teaching.

    Most medical graduates are not in a position to practice on their own after graduation. Most enter training schemes lasting 5-10 years. They work for Trusts, providing service, but are trained along the way. Their salaries are in the large part in NI funded by NIMDTA, the medical and dental training agency, part of the Dept of Health. Most trusts would struggle to replicate the service provided by trainees if they weren’t there. Yes, the state is supporting their salaries but not the NHS directly.

    Most medical graduates need to work in training posts for several years before they could set up on their own in the private sector if they wished. Most are being lost to training posts overseas, that are being funded by the mechanisms present in those countries. The reason is that those countries provide better terms and conditions while they train. Remember, the UK has benefited in the last from significant numbers of international graduates filling training posts here to provide service. This is just the previous situation reversing!

    Requiring medical graduates in the UK to work for the NHS for x years won’t change much. If anything it will make UK medical schools less attractive and increase the brain drain at an earlier stage than now.

  • Vince

    There has been an almost complete lack of workforce planning for 10yrs, only recently being addressed. Sadly workforce reports are now gathering dust on shelves due to a lack of leadership at DHSS.

  • El Daddy

    But readers from outside the island would never have any reason to refer to the state as Éire anyway, it is simply Ireland.

    Regardless, are there any problems that you know of that are more specific to the NHS in NI?

  • Vince

    The problem is that after Foundation training too many of them are not entering training positions. They do not have to work for “several” years before they can do this. Some of them are even setting up their own private companies/chambers to sell their services. I am aware of one major medical specialty locally that will have 50% of its core medical training posts vacant next year and 40-50% of its specialty training posts will also be vacant from August. This is a critical challenge to delivering patient services.

    Just to clarify, without the NHS, medical undergraduate training could not be delivered. It is entirely reasonable to expect graduates to commit a significant proportion of their postgraduate training/service to the NHS particularly if this is coupled with the removal of tuition fees.

    When doctors reach consultant level, again benefitting from NHS training and reputation, they can easily earn £600/hr + through the private sector if they so wish in addition to a substantial NHS salary.

  • Korhomme

    Vince, I don’t know how many people there are who are full-time locums and who don’t have a regular NHS job. It may suit some in the short term; in the longer term, it may make getting regular employment more difficult. I’m not sure what research has been done into this.

    Certainly, when I was in training it was usual, almost expected, that we would spend a period abroad, though this was also counted as training. This was usually in the senior registrar position; it represented the last opportunity for such experience before permanent employment. The NHS has never offered sabbaticals. Most in surgery went to the US, or to South Africa or Australia. I spent two years in Switzerland, and this counted towards my ‘certificate of completion of surgical training’.

  • Korhomme

    The problem with ‘Ireland’ is that it has to be modified as the ‘Republic of Ireland’ lest people think it refers to the whole island.

    Specific local problems? I’m not the best person to answer this, I’m too far from the front line. I’m aware that the spending per capita here is much higher than in England (IIRC, around £2200 against £1800) but I’m not entirely sure why. And of course we have ‘too many’ hospitals, and they are the ‘wrong’ size and in the wrong place.

    GP retirals do seem to be as much of a problem in terms of replacements in England as they are here. And there is in both places the increase in the numbers of the aged who do need more medical attention than the young.

  • Korhomme

    Thanks for the clarification; ultimately, it is the state and thus the taxpayer that is paying, even if the funds are shunted around through various bodies to cover either service or training.

  • Vince

    This is exactly the point. In the training scheme that I know best most trainees spend 1-3 years out of programme elsewhere, often in Australasia/GB, and some of this will count towards completion of training. Such a move would usually take place sometime 6-9 years after graduation.

    Re: locums, full time locums are increasingly common although accept that some may only do these for 1-2 years.

  • El Daddy

    Well personally if I was to use a qualifier to distinguish between Ireland and NI, I would say “the Republic” / “ROI”, rather than Éire, in every instance. “Eire” (without the fada) was popularised by the UK government in 1937 after the Irish Free State became Ireland, as they didn’t fully accept the claim that it was a national sovereign state for all Irish people, but has fallen out of official use since the Good Friday Agreement and they now use the proper term of Ireland.

    But anyway..! Getting GPs is a big problem in the rest of Ireland too – roughly 50% of GPs are over 50, which doesn’t bode well unless something is changed soon. Thankfully we do have a younger population that the UK so the effects won’t be as immediately acute.

  • Korhomme

    If those who opt to set up private companies do so, this is surely a market-driven response which neo-liberal governments would in other circumstances applaud.

    Behind it must be the question, ‘why are they doing this?’ There have always been medical entrepreneurs, though most medics haven’t been very business orientated. Is there something fundamentally wrong with working in the NHS today?

    At consultant level, private practice is certainly possible; but there are specialities where there is very little — geriatrics, for example, or mental disability, or prosthetics. (It also partly depends on what is meant by ‘private practice’.)

  • Korhomme

    Agreed.

  • Doctor M

    Yes, ultimately it is the taxpayer, but then again all degrees are subsidised by the tax payer to some extent. Should all graduates be made to work for the civil service.

    Equally, many degrees include an element of working in industry. The providers of these placements get paid for this. We don’t see those graduates being forced to work for the providers of their placements. That’s why the funding mechanisms are important to discuss with the topic.

  • Doctor M

    True. Trusts benefit from the status of being a teaching hospital and all the kudos that attracts. It also helps to attract the best consultant talent. As alluded to before trainees (post graduate) are a cheap source of medical labour for hospitals as many hospitals have found out when trainees have been withdrawn.

    Watch the English NHS for a much more free market approach to medical education. Training is already being formally commissioned, and like health care, this can also be commissioned from the independent sector I.e. Private clinics being paid by the government to take trainees and medical students. This will completely turn these arguments on their heads by taking the sacred cow of the NHS out of the equation resulting in most of the populace losing interest.

  • Old Mortality

    I’m sorry if I’m belabouring this point, but why does the NHS not simply refuse to pay the rates demanded from agencies. I appreciate that that this might cause temporarily difficulties but, in NI at least, it would surely ‘put manners’ on the agencies and those who use them. In the meantime, the NHS could increase its overtime rates and still save money. Or am I missing something fundamental here?

  • Old Mortality

    At the risk of inciting feminist venom, I came across some figures a while ago which showed a dramatic increase in the number of female GPs. For obvious reasons, could this also be factor in the increasing demand for locum GPs?

  • Old Mortality

    ‘Fast track: surgery and much of internal medicine, cardiology and gastro-enterology, and radiology is based around manipulative skills, the use of implements. It’s been said that to get really good at such skills takes 10,000 hours of practice — the same whether you are a concert pianist or a surgeon. If this is correct, it makes fast track difficult.’
    Maybe ‘fast-track’ was a wrong choice of term but if takes a lot of practice, is intellectual capacity vital?
    ‘both nurses and doctors can be very protective of what they see as their own areas’
    I think both can be guilty of taking themselves too seriously. It is the job of government to resist such sensitivities in the interests of efficient provision.

  • Korhomme

    The present SoS was the co-author a a pamphlet about a decade ago; it advocated privatisation of the NHS. You don’t have to be that cynical to think that privatisation is being attempted ‘by the back door’ and through the usual ‘death by a thousand cuts’. (And check up the ties between the previous SoS and private medical companies.)

  • Korhomme

    It very probably is. GPs can be either principals or salaried. Salaried GPs have regular working hours, and need not do night or weekend work. In the right circumstances, it can be a very good choice for some people, specially those with a young family.

    Rather more than half of all medical graduates are now female.

  • John Collins

    Well OM there are a variety of reasons why it suits management to use agency staff, among those are
    (1) They do not have to give them holidays, premium allowances or do they qualify for pension entitlements
    (2) Staff are recruited as required and do not have to be roistered as of right to so many shifts a week
    (3) If somebodies standard of performance is not good there is no big deal about sacking them, you just do not allocate them again.
    (4) A staff riddled with agency workers are seldom if ever represented by strong and thus awkward unions.

  • John Collins

    Do all the doctors and nurses trained in other countries, who come to the UK and ROI, have to reimburse their own countries exchequer, before they come to the NW Atlantic Islands?

  • whatif1984true

    A first year doctor can earn well over £30k taking into account all the extra payments for shifts/nights etc.

    Regarding hours there is unlawful but ongoing exploitation of young doctors. F1 doctors working in hospitals are working additional hours every shift which are over and above their shift hours ie doing 14 instead of 12 hours. This is not welcomed by young doctors but they are powerless/frightened to fight it. This seems to be accepted within the profession. It is not surprising that a young doctor will look elsewhere for work when such attitudes prevail.

    Regarding tuition fees with the GOVT requiring nurses to pay fees it seems unlikely that fees will not increase. If they do I wonder how effective the GOVT is chasing fees from Drs who move abroad.

    If Drs tuition is considerably greater than any other degree then charging more or requiring a period of service is equitable.

  • Korhomme

    Not just that; as an EU member, students can qualify in medicine universities in central/eastern Europe. Instruction is in English. Vast fees aren’t charged, and as long as the UK remains, such newly qualified doctors can return to the UK.

  • Korhomme

    I’d be pretty sure that the conditions of work are a significant driver for the exodus of young doctors wanting to leave; not the ‘expressed’ conditions as in the glossy presentations, but the reality of the work.

    Nursing bursaries have been stopped; I read that there has been a reduction in the numbers of students applying to be nurses (it might have been a reduction by a third). There have been problems with nurse recruitment for some time; many now come from abroad. Much the same sort of problem I imagine.

  • thank You for such nice post

  • whatif1984true

    I would be interested in your thoughts on the assertion that nurses in training spend the majority of their time in a hospital doing useful work. Why they would have to pay to do this seems odd .

  • whatif1984true

    No one ever raises the question of how a nurse with a young family is supposed to arrange daycare when he/she is working different shifts each week. Nurseries will only offer a place for specific days each week. There should be nurseries run specifically to care for the children of staff who have to work irregular shift patterns and at weekends etc. This alone might make a huge difference to the recruitment and retention of staff.

  • Korhomme

    I haven’t worked in a hospital that trains nurses for a long time. What you say is certainly odd, but I’m not best placead to comment accurately on it.

  • Korhomme

    I believe that some hospitals have nurseries/creches for kids that allow regular hours. It’s also a problem for young medics, and I imagine for other staff with erratic patterns of work.

  • aquifer

    £350m extra a day for the NHS? Try £500m a year less:
    https://www.theguardian.com/society/2017/may/31/nhs-faces-500m-a-year-bill-post-brexit-for-returning-retirees-says-thinktank
    Gotta keep getting those senior BR-exiteers to the polls!