Despite “run through” blackmail, a large majority of doctors are opting out and taking a career break.

Despite “run through” training blackmail, a large majority of doctors are opting out and taking a career break. The Foundation Programme was first proposed by England’s Chief Medical Officer, Professor Sir Liam Donaldson in 2002…. Some countries, (India) use financial measures to entice their doctors to work for the state for their first 5 years. Doctors can be posted to unpopular outlying areas, so they try to avoid this, and even borrow to pay their way out. The “Perverse outcomes” of the foundation programme could only have been avoided by overcapacity of doctors and it has been through many administrations that places have been rationed.

Since “run through” training (GMC)  was advanced, and the penalties for “uncoupled training” were made clear at the start of the “Foundation Programme”, the profession have felt bullied, and coerced into a narrow based training, rather than the broad based training of yesteryear.

Knock on effects mean that opening up an abdomen often needs several specialities present. The convention of Human Rights states that a person may elect to take his skills to anywhere that wants and allows him, and in Europe this is part of the free movement of people in the European Convention of Human Rights. SO blackmailing doctors to stay in the UK, for fear that they will not get posts on their return, has backfired. The profession as a whole has voted with it’s feet. There is a world market in doctors, and medics reserve the right to take their trade where they wish. A perverse outcome from the wrong incentive at the wrong time…

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The BMJ Editorial by Jennifer Cleland, John Simpson, and Peter Johnston “Doctors opt out of training after foundation years,” (BMJ 2019;365:l1509 )

The UK’s inflexible training system looks increasingly unsustainable

There has been an explicit assumption in the UK that doctors will seamlessly progress upwards through the postgraduate training pathway. This was perhaps the case in the early years of the UK’s foundation programme (the first two years of generic training following medical school)—in 2010, 83% of foundation year 2 (FY2) doctors progressed directly from foundation to specialty training, including primary care. By 2018, however, that figure had fallen to 38%.1 Nearly two thirds of UK medical graduates now opt out of the training pathway at the first natural opportunity.

Most doctors who opt out return to specialty training within three years.2 This suggests that the break from formal training is the postgraduate equivalent of gap year—a time to recuperate from intense educational experiences, resolve uncertainties about the next steps in life, and make a curriculum vitae more competitive.345 Qualitative research suggests these are common reasons for not entering specialty training after FY2.5

Taking dedicated time to plan a career that may last more than 40 years is sensible. That doing so does not align with our current training system suggests a need for change. This is already happening. Doctors are opting to work overseas for a year or two, or take a “service job” (a post which is not linked to a formal training programme) to gain experience. Academic or clinical fellowship posts are also proliferating.2 These posts are designed to support medical education and other areas of activity, such as quality improvement, usually combined with some clinical service—often supporting rota gaps. These posts work for individuals, and also work for the NHS by keeping early career doctors in the UK.

But they are an isolated solution that could cause ripple effects throughout a complex training system.6 Fellowship posts, for example, are largely funded with money saved from unfilled specialty training posts. The two options compete for funding and are at the mercy of shifting trends. Fellowships will be a sustainable option only if they attract independent funding as, in the current system, an increase in the uptake of specialty posts would decrease the funding available for fellowships.

More fundamental changes to postgraduate training should consider the following: the interactions between individuals and the system at different points in the pathway; how different elements of medical education and training relate to each other and to the wider social and political landscape; and how systemic changes may benefit training and, ultimately, healthcare. Research shows, for example, strong connections between admission decisions by medical schools and the choices made by FY2 doctors about both specialty and place of work.78

The relation between medical school admissions policies and medical workforce planning is not simple or linear.9 Shifting the focus of admissions, however, from a stifling emphasis on high academic achievement10 to a model better aligned with social accountability would be a good first step towards a better match between the two. Such a model would select a mix of students with the personal attributes and motivation to train and work in the NHS, across the full range of localities and specialties. To facilitate this change, selection policies should consider the views of a broader cross section of stakeholders, including representatives from community and hospital medicine, employers, patients and the public, and government.11

Similarly, medical education and training in the UK involves many separate systems, including medical schools, the Foundation Programme, postgraduate training providers such as Health Education England and NHS Education for Scotland, and the royal colleges. All must work together across boundaries to ensure a smooth transition between foundation and specialty training. Consider, for example, the potential value of aligning medical school admissions (such as dropping the high academic requirements) with increases in intake (through government reform) and royal colleges rethinking how training programmes are constructed, assessed, and regulated.

Change may be unpalatable, but the alternative is to continue with the current state of affairs—an inflexible training pipeline that fails to supply enough doctors to meet growing demand and fails to meet the needs of doctors in training. Acknowledging that systemic and structural problems exist is the first step towards developing effective, system-wide solutions.

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This entry was posted in A Personal View, Perverse Incentives, Professionals, Rationing, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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