You can find my most recent commentaries on the Junior Doctors’ crisis as it unfolds in 2008 by following this link.
The crisis facing Junior Doctors in the UK is complicated and heart-wrenching. It is also confusing. Most of the people who write about it are either directly involved and assume a lot of prior knowledge, or they are not directly involved and find it too complicated to understand. It has taken me months to get my own head around it, but I think I have managed that now.
In a nutshell, we have more people whose ambition is to become a consultant than there will be consultants’ posts for them to fill. This blog entry explains how and why we got to that situation. It also explains that instead of encouraging these specialists to remain in the NHS and improve the quality of the Heath Service over all during the next decade or so, (credit then being taken by the next government, presumably the Tories), Blair and Hewitt are forcing the issue now in a way which will result in a huge number of specialists leaving the NHS altogether. It does so without anger but with a lot of sarcasm.
Sit tight, and I’ll do what I can to explain it.
A decade or more ago there was a real shortage of Junior Doctors. It was not an attractive profession at the time. It was expensive to get into, not particularly well paid, and they had to work crazy hours. Putting it crudely, each hour that a consultant works in a hospital generates n number of hours of work for his or her juniors. The NHS saved money on junior doctors by paying them a fixed salary, and then getting a hundred or so hours out of them per week. But the ratio of numbers of consultants to numbers of junior doctors was pretty tight. Yes, there were more junior doctors than consultants, but it wasn’t that many more. It was reasonable for any junior doctor to expect to become a consultant one day, because enough of her peers would become GPs (a very family-friendly form of doctoring) or leave the profession to have incredibly clean and well educated children, or decide that medicine was too messy and leave to work for a pharma company or law, or to become a journalist or comedian instead.
So far, so exploitative.
Then, in the late 1990s, the sainted Blair decreed a solution for this, and did two things. One long term, one short term. The long term solution was to increase the number of medical school places. The short-term solution was to reduce the number of hours junior doctors could work, and invite overseas-trained doctors to come here and help us out.
So far, so visionary.
Now, though, junior doctors are working reasonable hours, (40-60 rather than 80-120), and the home-grown med-school graduates are out on the wards.
Bingo. You’d think.
This of course means that the ratio of Junior Doctors now to Consultancy posts in 15 years’ time is even more fiercely competitive than before. The obvious and sensible thing at this point would be to make it easy for doctors to continue as specialists without going for full consultancy in the same way that teachers can choose to remain subject teachers, to become department heads, or year heads, rather than going for deputy headship or full headship. There is no shame or failure applied to those who decide to continue as full-time teachers rather than going for the glories of the headship. The model is there. The benefit of applying this to the medical profession is that it there would have been a raised level of experience on the wards from doctors who continued as specialists without being shamed by not becoming consultants. The simple way to have achieved this would be to to close the door behind the existing overseas-trained doctors, keep the ones we’ve got, and choke back the tap very slightly on the medical school intake. The bulge of doctors who started on the wards some four or five years ago would progress more slowly in the profession than their older or younger colleagues, but we would keep their accumulated skills and experience.
So far so obvious. But not obvious enough for Tony Blair and Patricia Hubris.
Instead the government has decided to do four things simultaneously.
1) Reduce the amount of time it takes to train to become a consultant. I have no idea what the logic is behind this, but it means of course that there are even more people eligible to be consultants than there were previously.
2) Withdraw the work permits of the overseas doctors. So people who have lived here, working incredibly antisocial hours, supporting our beleaguered NHS, improving the access to health-care in places with a high immigrant population as well as making the numbers up right across the country are suddenly surplus to requirements. Forget the fact that they may be married, have children, have friends and a life here. Ship the scroungers back home! No one’ll miss them.
3) Force the locally trained surplus of young specialists into pre-consultancy roles now, as a single exercise, implemented this year only. Make sure that the numbers are exactly right. Do not put slack into the system to account for the fact that increasing numbers of doctors are women and might appreciate a more family-friendly workload. Do not put slack into the system to account for changes in medical technology which might mean that some specialities needed more consultants than before. Above all, do not give the doctor time to prove whether or not they would make good consultants. Oh no. Make the choice now. Make it once.
4) Discard the waste. Who needs unnecessary doctors, anyway?
This is like looking at a bunch of five year olds in a swimming pool and selecting your national swimming squad for 2017-2027 now. No second chances. No time for re-thinks. No chance to change your mind.
It beggars belief, doesn’t it?
It should be stressed that for doctors who are two, three or more years into their speciality training they have had one chance and one chance only to continue it. For those who were not selected by the MTAS process two weeks ago, their chance to continue as specialists has gone for good. They are explicitly prevented from applying again. The options open to them are to leave the profession, leave the country, or hang around locuming and looking for non-specialist Trust jobs. So, no, they probably won’t be unemployed, but by far the majority will either leave the country or leave the medical profession. Is this really the best use of the time and money they and we have spent getting them so far?
So, if you live in the UK or are a British Citizen abroad, I’d appreciate it if you’d consider how it can possibly be good for the nation’s health to discard a fifth of a single generation of doctors in just one year. If you find it as confusing as I do, then you might like to consider signing the Downing Street petition asking the government to return the control of medical training to the Royal Colleges.
Part 2 looks at the way MTAS forces doctors to relocate at random around the country, uprooting their partners and families in the process.
Part 3 considers the academic research on recuitment and assessment methods and discovers that the Self Assessment Competency Questionaires have been invalidated by the way in which they have been introducted.
Part 4 considers the debt we owe to the overseas-trained doctors and how we are repaying it. With a kick in the teeth, basically.