The Times 4th April reports on the front page (lack of doctors), comment and in it’s editorial. Editorials should be informed and have a balanced helicopter view. What these articles and the leader in particular fail to mention are the following:
There is no NHS (Yes, it’s official and the WHO has said so). There are 4 different systems, and with Manchester arguably 5.
Too few pilots in the Battle of Britain: Too few Doctors in the battle for the UK health systems Undercapacity is what drives the locum culture. The world marketplace for medics is a reality. Doctors have a choice of where they work once they qualify.
More debt for medical students will not encourage applicants from poor families
Despite competition for places we still recruit a large number of overseas doctors.
Graduate entry to medical School gives better value to the state. More mature applicants, albeit with larger debt, stay in the profession longer and perform better.
We need to bring more men into the profession.
The reasons for behaviours need to be made overt, and political denial needs to stop. The Honest debate asked for by Mr Stevens has not even begun.. The profession is disengaged, fearful and feels its leaders are hapless and hopeless: even the “Thunderer” fails to provide an accurate diagnosis.
Mathew Syed opines on and blames doctors for the culture of fear. Blame doctors’ egos for these disastrous errors – If the new NHS investigations agency is to succeed, senior clinicians must swallow their pride
Hospitals are paying locum doctors for hours they have not worked in an attempt to get around government cost controls for agency staff, Britain’s most senior emergency medic has revealed.
Doctors are refusing to work locum shifts for the lower rates imposed by ministers, leaving A&E units dangerously short-staffed, Cliff Mann, president of the Royal College of Emergency Medicine, said….
Kate Gibbons reports (unbelievably) that: Brexit would put the NHS at risk, health leaders warn which is a rant against tribalism.
And an unnamed, presumably Chris Smyth opines in the leader: Train More Doctors – There is a way to stop agencies and overpaid locums fleecing the NHS (with apologies for full reproduction):
It is late on a Friday afternoon. The manager must ensure that the A & E department is fully covered for the weekend. This requires six doctors. Five are available from the hospital’s own staff. A sixth has been booked from an agency but the agency calls at 5pm to say that its client has had a better offer from another hospital and intends to work the night shift there instead.
The manager has learnt the painful lesson of the Mid Staffs scandal. Patient safety must come first. He or she has no choice but to match or beat the competing hospital’s offer, however absurd the locum’s shift rate is as a result, however disastrous the knock-on effect of such bargaining may be on the hospital’s annual accounts. Worse still, as we report today, the manager may pay the locum for hours spent “travelling” (but not working) in order to get around caps on the premium allowable for temporary over permanent staff.
If the NHS overspends this year, payments to agency staff, nurses as well as doctors, will be a main reason. Such payments are expected to reach £4 billion in total, up from £3.3 billion in 2015. When they involve book-keeping tricks, such as paying for hours not worked, they are a fraud on the taxpayer. When they involve British-trained medical staff they are a disgraceful response on the part of those staff to the excessive generosity of a system that has heavily subsidised their training. When locums are hired from abroad other countries lose doctors. The need for them is, above all, a function of a simple and avoidable imbalance of supply and demand.
There are not enough doctors in the NHS. In addition to encouraging them to opt out of staff work in favour of the lucrative life of a locum, this has enabled junior doctors to hold the service to ransom with the threat and reality of strike action. However else the government responds to this shortage, one thing is clear. The NHS must train more doctors.
In the last detailed survey of doctor numbers in advanced economies Britain ranked 23rd out of 34, behind the OECD average and much of eastern Europe. Given the cost of medical training to the exchequer, this is hardly a surprise. As of 2014 it cost nearly £500,000 to train a GP and more than £564,000 to train a consultant. Medical students pay standard tuition fees and living expenses in their undergraduate years but otherwise these training costs are borne largely by the wider NHS.
It shows little gratitude for doctors trained at public expense to exploit their own scarcity through agencies that bid up NHS hospitals against each other. Yet ultimately it is not doctors’ fault that they are in such short supply. Nor is it hard to understand why some choose the high hourly rate and flexibility of locum work over the vicious circle of staff shortages and high pressure on some hospital teams.
The solution is to restore logic to a broken system by allowing medical schools to take on more students while requiring students to shoulder more of the cost of their training. At present, places in British medical schools are over-subscribed and over-subsidised. This creates a bottleneck that ill serves the public and gives doctors too much power. It is time to put patients first.
Sir, The European working time directive has had a deleterious effect on both training and staffing in hospitals (report and leader, Apr 4). Equally important is the retention of newly trained doctors, given that about half completing their basic training do not continue to work in the NHS. Whatever the reason for that, any move to “train more doctors” would seem to be throwing good money after bad.
Hospitals now are in many ways deeply unattractive places to work The system by which one was part of a sort of “family” who supported each other has been dismantled, and shorter hours and shift working mean that a trainee often does not have the fascination of following a particular patient’s progess (and thereby incidentally learning by experience). Staff shortages mean that one is always firefighting and coping with the inadequacies of the system. It is largely a lonely and dispiriting grind now, and personally I needed a lot of money to make doing extra sessions an attractive proposition.
Moreover, it always struck me as odd that although the European working time directive stopped us from employing our own junior doctors as locums because they would then do too many hours, they were free to do locum work in another health trust. I remember having a trainee with me on an operating list on a Monday morning who was plainly yawning and half asleep because he had just spent a weekend, including the previous night shift, working at another hospital on the other side of London.
Jane Stanford Retired consultant anaesthetist, London SW13
Sir, Your leader “Train More Doctors” is correct. However, this is only part of the solution. Currently about 50 per cent of doctors who qualify do not then work in the NHS. They go abroad or work elsewhere, such as the City, pharma or biotech. There should be an obligation on all newly qualified doctors to work in the NHS for a period of time, perhaps five years. If they leave within that time they should be asked to repay a significant amount of money (£100,000-£200,000?) towards the cost of their training. This would surely be preferable to increasing the tuition fees they pay. This technique is used in the army. If, having completed the commissioning course at Sandhurst, an officer decides not to take up his commission, he is asked to pay back £25,000 as a contribution to the cost of his training.
St John Brown
East Grinstead, W Sussex
Sir, I understand that there is now a very high proportion of women students in our medical schools, and that many women doctors are likely in due course to move to part-time appointments.
Given that the role of medical schools must be to deliver the full-time frontline doctors that we need, surely the number of young women allowed to begin training should be considerably limited to allow in more young men who will give a full career of medical service and provide society with much better value for the money spent on medical training.
Emeritus reader in economics, LSE
Motivation and Morale
Sir, My son Oscar was a junior doctor in Nottingham, now he is a resident doctor in a hospital in New York. The contrasts are illuminating: he is paid no more in the US than he was in the UK, although his working hours are 50 per cent longer. Last weekend he worked both nights for no extra pay.
He would say that there are two main differences that make the US experience superior. The first is teaching: 14 hours a week in the classroom as opposed to two in Nottingham. The second is how he is valued. Speak to any UK junior doctor and they will complain that they are treated with disdain. In New York, Oscar is an integral member of a highly motivated team.
House of Lords
Sir, Matthew Syed (Opinion, Apr 4) criticises doctors for concealing “medical errors” by calling them “complications”. In fact complications are much more important. Most, if not all procedural complications are the result of some error of judgment or execution (rather than incompetence) which carries a small but not insignificant risk. By law, patients must be “consented” for these risks and the possible complications. Fortunately most mistakes or errors during a procedure do not result in harm because they are recognised and dealt with during the operation. There is therefore no clear distinction between a mistake and a complication, but it is usually the latter that is associated with irreversible harm.
In this age of ever-increasing scrutiny, reputations are forged by competence and honesty rather than “status”. As a cardiologist practising complex procedures at the highest level for more than 30 years, I have rarely encountered a cover-up motivated by an individual’s ego. On the other hand, as recent NHS whistle-blowing inquiries have shown, institutional cover-ups are rife.
Dr David E Ward
Cardiologist, London SE22