pH7 Magazine - Is There A Doctor in the House

There is no question that there are now more doctors working in the NHS than ever before, but are there enough to meet the incessant demands of an ever-expanding and evolving health service?

In the summer the government published figures showing how it had successfully met – well almost (they just missed out for consultants) – its recruitment targets as set out in the NHS Plan. Yet many argue that these were fairly modest targets and that we actually need many more doctors to meet the challenges that lie ahead.

The shortage of doctors was one of the major flaws in the NHS Plan. The plan was ambitious and its follow-up – the more recent NHS Improvement Plan – is likely to be an even bigger test for the NHS over the next five years. The NHS Plan pledged to recruit an extra 2,000 GPs and 7,500 more consultants by 2004. The BMA calculated that 10,000 more GPs would be a more realistic number to meet the government’s objectives and perhaps as many, if not more, consultants are needed to deliver the quality of care patients have a right to expect.

The UK is already under-doctored. It falls far below comparable countries on its doctor-patient ratio, with only 1.8 practising physicians per 1,000 population compared with an average of 3.29 among European countries. Years of under-investment in the NHS has led to this situation and the government does recognise that it has a lot of catching up to do.

In 2002 the Wanless report looked at medical manpower needs up to 2020 and foresaw a need for an extra 62,000 doctors, but a shortfall on that target of 25,000. Even if we meet the Wanless target, we will still be below the EU average and we cannot predict how other European medical workforces will develop.

The European Working Time Directive poses an enormous challenge to the way health care is managed and delivered and will put further pressure on capacity. This health and safety legislation, which came into force in August 2004, limits the amount of time junior doctors can spend in hospital to 58 hours a week. The BMA has calculated that this will mean a fall in the manpower available to the NHS of up to 213,000 hours a week – equivalent to 3,700 junior doctors. In 2009, when the limit on hours falls to 48 a week, the total loss of manpower could be as high as 476,638 hours a week (9,900 junior doctors).

While some of this shortfall can be met by changing the roles of other health care professionals to support the work of doctors and by introducing different ways of working, it is only part of the solution. Without a substantial increase in the number of doctors, many of the changes we all want to see will not be achieved.

So where will all these extra doctors come from?
The government has already taken an important step and increased the number of medical students by some 2,000 places. By 2005 there will be 5,894 medical school places in England, compared with 3,749 in October 1997. However, it takes nine or ten years to train a GP and around 15 years to produce a fully trained consultant, so it will be a few years yet before we see the benefits of this expansion.

Experts argue that despite this generous expansion, we still won’t have a medical workforce that can cope.
The government has looked to other countries to plug the gaps in our medical workforce and launched a recruitment campaign. The UK has a long history of recruiting doctors from overseas to sustain our own medical workforce. Considering that the UK is the fourth largest economy in the world, it is disgraceful that we are still taking doctors away from other countries – often from places that need them more than we do.

Private companies are now bringing in teams of overseas doctors to help the government reduce waiting lists. Some patients will be sent abroad for their surgery. But these quick fixes are only short term solutions and will do little to alleviate the shortfall.
There are actions the government can take now to help build capacity.

For starters, they should bring in more measures to help keep doctors in practice when they might otherwise opt to retire or leave the NHS. The BMA’s own study of 1995 medical graduates paints a picture of a generation of doctors who are looking for a better work-life balance. Almost three-quarters of the 490 doctors surveyed are either working part-time or would like to in future. Yet only four per cent (around 1,700 doctors) are currently training on a less than full-time basis.

There are some 12,500 doctors working in the staff and associate specialist grades. They offer a huge pool of untapped skills. It seems pre-eminently wrong to continue draining the developing world of its medical staff when better use of these doctors would improve patient care and allow waiting lists to be cut.
Hundreds of medically qualified refugees and asylum seekers in the UK are desperate for work, but face many hurdles trying to secure employment. It costs £250,000 to train a British medical student to become a doctor, but as little as £10,000 to prepare a refugee doctor to practise.

I seriously doubt that even after implementing all these measures we will have a sustainable medical workforce that is fit for the 21st century. We must keep making the case for more trained doctors. But I stress more fully trained doctors is the only way forward.
The government is changing the way in which the future generation of doctors will be trained. The Modernising Medical Careers project is set to transform postgraduate medical training and while the BMA broadly welcomes the principles, the devil lies in the detail. The end result for doctors currently training in the new foundation programmes is still unknown. What sort of “specialty” training programme will they be expected to follow and how long will it last? Will the end product of “consultant” be the same gold standard we have today?

We want to see change, and doctors will play their full part in helping to bring about these reforms, but having a workforce that is up to the job is a basic requirement. What we must be sure of is that we continue to produce consultants who have a wide range of skills and experience. Patients may present with a wide variety of symptoms or have other underlying illnesses. It would be highly undesirable if new training schemes led to any reduction in consultants’ expertise.

In both medicine and surgery, even if trained in a sub-specialty, they must be able to deal with emergencies in the generality of their specialty. Without them, we will not be able to keep hospitals open at nights and weekends and patient care will suffer.
I do genuinely wish the NHS plan well, but unless we have the doctors we so desperately need, we will not have a health service that we can be proud of in the years to come.