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.