Will boosting the number of ‘home-grown’ doctors make us self-sufficient?

Vivek Kotecha examines whether the government’s announcement of 1,500 extra medical school places will make the UK self-sufficient in doctors given the staffing issues faced by the NHS.

The government’s recent announcement of an extra 1,500 (25%) funded medical school places is welcome news.((Department of Health and The Rt Hon Jeremy Hunt MP. Up to 1,500 extra medical training places announced. October 2016. https://www.gov.uk/government/news/up-to-1500-extra-medical-training-places-announced)) However, on closer examination this appears to be more a political gesture than a considered attempt to help resolve the staffing issues faced by the NHS.

Short term issues

Of chief concern is that the additional 1,500 medical students won’t begin graduating until 2023/4, however the NHS needs extra doctors now to fill the existing acute shortages of staff. Data released by the Royal College of Physicians in 2016 showed that across the UK 40% of advertised consultant positions were vacant due to a lack of trained applicants. One fifth of consultants thought that rota gaps were causing ‘significant problems for patient safety’.((Royal College of Physicians. One fifth of consultants state that rota gaps are causing ‘significant problems for patient safety’. February 2016. https://www.rcplondon.ac.uk/news/one-fifth-consultants-state-rota-gaps-are-causing-significant-problems-patient-safety))

In addition, an estimated 13,500 consultants and GPs will retire in the 5 years to 2019, and taking these into account, an extra 9,400 posts will need to be filled by 2019, a growth rate of 2.2% per annum.((They Work For You. Doctors: Retirement. Department of Health written question. November 2015. https://www.theyworkforyou.com/wrans/?id=2015-10-29.14061.h)) Up until now much of this growing demand has been filled by doctors trained abroad. Thirty-three per cent of last year’s registration applications were made by doctors from overseas.((General Medical Council. Working with doctors. Working for patients. Our annual report: 2015. http://www.gmc-uk.org/Annual_Report_2015_0816.pdf_67296034.pdf)) With this in mind, the disparaging comments regarding 'foreign workers' made at this year’s Conservative Party Conference are highly discouraging. The NHS will require international medical workers to fill the shortages in the 8-15 years it will take train up enough 'home-grown' doctors to become trainees and specialists. If overseas workers are under the impression that they may be removed, once the NHS is self-sufficient in doctors (scheduled for the end of the next parliament), then NHS managers may well find it costlier to recruit to fill the current and expected shortages.

A further worry concerns the £100m cost of funding these extra places, which does not appear to be provided for by additional money. If this is so, the question is where will the extra funding come from? Since Health Education England (HEE), who lead and coordinate health education and training nationally, has had its budget frozen until 2020/21, it seems likely that this extra £100m will have to be taken from other areas.

Medium term issues

The NHS has serious unresolved issues with staff retention which the proposals may exacerbate. Only 52% of last year's medical graduates chose to stay in the health service - the lowest recorded.((Financial Times. Jeremy Hunt aims to boost number of ‘homegrown doctors’. October 2016. https://www.ft.com/content/b8c7cc60-8986-11e6-8cb7-e7ada1d123b1#axzz4M23hjQfg)) NHS staff sickness rates are 27% higher than in any other public sector organization with 39% of cases citing stress and overwork as the causes.((Nuffield Trust. What will be the real cost of poor NHS staff wellbeing? October 2015. http://www.nuffieldtrust.org.uk/blog/what-will-be-real-cost-poor-nhs-staff-wellbeing)) The ongoing junior doctor dispute, demands for 7 day services, and high tuition fees may also deter a high proportion of students from practising medicine even if more complete training. Ward pressures are already having an impact on the quality of student placements.((Nursing Times. Exclusive: Quality and quantity of student placements at risk from staff shortages. February 2014. https://www.nursingtimes.net/roles/nurse-educators/investigation-ward-pressures-hit-student-placements/5067842.article)) With increased vacancies to 2020 and beyond, it seems reasonable to question whether there will be enough senior doctors to supervise an extra 1,500 medical students each year?

The effects of these proposals may not be limited to the supply of doctors, they may reduce the numbers of nurses and allied health professionals being trained too. These problems are symptomatic of wider failures in workforce planning. In 2012 the government decided to reduce medical training places by 2% a year for fear of an oversupply of doctors.((British Medical Association. BMA accepts cut in student numbers to reduce unemployment. December 2012. https://www.bma.org.uk/news/2012/december/bma-accepts-cut-in-student-numbers-to-reduce-unemployment)) While the announcement to reverse this decision is welcome, it ignores and may even worsen the chronic shortages currently experienced in nursing. Between January to March 2016 there were 30,00 vacancies for nurses in the NHS compared to the 9,000 doctors required. Demand for non-EU nurses is estimated to be 11,000 by 2020.((Health Services Journal. 'Desire to save money' caused NHS nursing shortage says damning report. March 2016. https://www.hsj.co.uk/topics/workforce/desire-to-save-money-caused-nhs-nursing-shortage-says-damning-report/7003565.article)) The HEE budget freeze has already led to the removal of £1.2bn of university funding for nurses and allied health professionals.((Health Services Journal. Exclusive: HEE budget freeze will have 'consequences' for NHS. November 2015. https://www.hsj.co.uk/topics/spending-review-2015/exclusive-hee-budget-freeze-will-have-consequences-for-nhs/7000603.article)) In March this year the Migration Advisory Committee criticised the government’s cut to HEE’s budget, which resulted in only one tenth of the 3,000 planned extra nurse training places being commissioned in 2016. If the £100m required for the extra medical school places draws further funding away from nurse recruitment and training the result could be a major staffing crisis.

Finally we note that the proposal to introduce mandatory conditions upon medical graduates ensuring 4 years minimum service in the NHS appears to be lifted from a report published in June 2016 by the think tank Civitas.((Stubbs, E. Supplying the Demand for Doctors. The need to end the rationing of medical school places. June 2016. http://www.civitas.org.uk/content/files/Supplyingthedemandfordoctors.pdf)) This report also made headlines for arguing that students who leave the NHS early should pay back a £130,000 'loan' for their 4 years of training, the loan to be paid off yearly (£34,000 p.a.) by the NHS to HEE if the student stayed.

While the idea of such a 'loan' has not yet been mooted by the government any such proposal raises serious questions about whether saddling trainees with debt and forcing them to train with the NHS is the best way to retain a highly capable and mobile section of our workforce. Should we not be focusing on retention, professional development, and public health prevention instead?