Workforce: Why Jeremy Hunt's plan to make the NHS self-sufficient for doctors is missing the point

Plans to make future medical graduates work for four years in the NHS were the last thing a profoundly demoralised profession needed to hear, argues GPC workforce, education and training lead Dr Krishna Kasaraneni. The government's plans to overhaul training also raise huge questions about funding, and risk turning off a generation of overseas doctors that the health service relies on.

Let’s examine Jeremy Hunt’s plan to compel future doctors to work in the NHS for four years after graduation and to make the NHS 'self-sufficient' for doctors.

What will it do to lift the morale of a service under extreme pressure? The answer is a simple one – absolutely nothing.

The proposal that newly qualified doctors should be made to work four years in the health service or pay back the cost of training misses the point completely. Patients deserve an NHS that doctors want to work for, not one they are forced to work for.

GP workforce

While the announcement comes with a long-overdue recognition of the extreme pressure under which our healthcare system in England is operating, the health secretary’s announcement is the first acknowledgement of successive governments’ poor workforce planning.

But this policy raises more questions than it answers. What happens to doctors unable to complete their four-year minimum NHS term, for example for health reasons or because they cannot find a job? How will the expansion in medical training be financed when the NHS is under intense strain?

It has been widely reported that the government plans to deliver 1,500 extra places at medical school with an investment of £100m. But 1,500 places at £220,000 each - the amount the government says it costs the taxpayer to produce a medical graduate - would cost £330m.

We know very well that the health secretary continues to struggle to get his head around seven-day GP services in the NHS, and his latest policy suggests he is not that hot on simple arithmetic either.

Another factor is that if you’re a bright sixth-former living in England, over the border in Scotland, Wales or Northern Ireland there are half a dozen excellent medical schools where – most likely – you won’t have to pay back the cost of training if you subsequently leave the NHS after four years. Has the health secretary even considered this? Most likely not.

GP training

And while general practice continues to struggle to fill its training places, the foundation programme for 2016 was over-subscribed once again. A total of 235 graduates had to be placed on a reserve list for places.

It has been touch and go with the foundation programme for years, and some medical graduates have faced an anxious wait – the NHS has appeared not to have the money to expand the number of places even slightly to accommodate extra demand. Increasing medical school places while not expanding foundation places still leaves this bottleneck and does nothing to improve GP recruitment.

So, how will the government fund an increase in training places to accommodate the new doctors? Is this all within the £100 million pot? The numbers now seem even more unrealistic.

Let’s assume then for now that Mr Hunt actually meant he'd invest an extra £1bn, rather than £100m. These extra doctors still will not become members of the medical workforce until 2023 at the earliest, and it will take at least another five years after that for them to become GPs.

In the meantime, the NHS would continue to rely on, and be enriched by, the contribution of international doctors. The government has said repeatedly that the diversity of NHS staff is one of its greatest strengths. So why is it seeking to reduce the diversity of nationalities?

It has been a deeply unsettling three months for many of the overseas doctors who work in the health service. For some members of the public, Brexit gave them an unaccountable green light for outpourings of racism. But even for doctors who escaped that abuse, there was suddenly an uncertainty they could never have anticipated.

Overseas doctors

It was as if the immeasurable enrichment that overseas doctors had brought since the foundation of the NHS was being reduced to that of a stopgap, a phase we went through until the as yet phantom legions of new British doctors could pick up the slack. A shoddy way to treat doctors who have often worked in the most hard-to-recruit specialties or the most deprived parts of the country.

The government might think this policy solves its Australia problem. In September last year 3,500 doctors across all grades applied for the necessary GMC documentation allowing them to apply for foreign jobs in just 10 days following the health secretary’s threat to impose a new contract on junior doctors.

But there are plenty of scenarios where this policy could actually increase the exodus to Australia, New Zealand and other countries where doctors seem to feel more valued. Some might stay for their foundation years, but not begin specialty training, instead carrying out other NHS work until they are free to leave. The government is currently accused of driving junior doctors away from Britain. It may also run the risk of permanently exiling them.

The profession is profoundly demoralised. The BMA’s cohort study published earlier this month found that 42% of specialty trainees were reporting high or very high stress, up from 29% in the previous survey.

So many of the reasons for this poor morale lie in the way that Mr Hunt has run the health service. Years of real-terms pay cuts, blaming the profession for being a ‘road block’ to seven-day services when the vast majority already work weekends, imposing a contract that was rejected by junior doctors in England.

Instead of tackling these sources of poor morale, doctors are effectively being compelled to stay in an under-funded and demoralised service. The health secretary’s offer is essentially a four-year contractual ‘wall’ to force ‘our’ doctors to remain in the NHS.

On a practical note, medical schools have always attracted students from around the world, with those from outside the EU paying much higher fees, which are a valuable source of income in further education. If they face immigration restrictions on working in the NHS, do they get penalised for it? If even a fraction of international doctors have to leave, or decide to leave, it will negate the 1,500 increase in medical students and leave the NHS in an even worse situation.

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