Category Archives: Medical Education

Why having so many women doctors is hurting the NHS: A provocative but powerful argument ……. Women should “lean in”..

For several years NHSreality has been advocating “graduate entry” to medical schools rather than undergraduate entry. It is simply better value for money, and it means that the gender recruitment gap is reduced or negated. If we add to that virtual medical schools run from centralised Deaneries, then teaching and learning can be in the communities that doctors live in and come from. Instead we have high performing female suburban school students ruling the roost for places as undergraduates, and, in general, they do not wish to work in the shires. Paediatrics is a case in point…

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Prof J Meirion Thomas writing in the Mail 2nd Jan 2014 opined on: “Why having so many women doctors is hurting the NHS: A provocative but powerful argument from a leading surgeon

By 2017, for the first time, there will be more female than male doctors in the United Kingdom.

Although I am a feminist — in the NHS hospital in which I work as a surgeon, some of the best doctors are women — this shift of the gender balance in medicine is a worrying trend.

I believe it is creating serious workforce problems, and has profound implications for the way the NHS works.

For many years — until the Sixties — fewer than 10 per cent of British doctors were female. Then things changed. For the past four decades about 60 per cent of students selected for training in UK medical schools have been female.

This is understandable in academic terms because girls achieve slightly better A-level grades than boys. They also mature earlier and may present themselves more impressively to medical school selection committees at the age of 17.

The effect is beginning to be seen. In 2012, a total of 252,553 doctors were registered with the General Medical Council. The male-to-female ratio was 57 to 43 per cent.

However, in its annual report last year, the GMC documented the changes in the UK medical register between 2007 and 2012.

The most significant change was that the number of female doctors under the age of 30 had increased by 18 per cent, while the number of males decreased by 1 per cent.

Indeed, in this age group, 61 per cent of doctors are now women and 39 per cent men.
In the age group 30 to 50 years, over the same period, the number of female doctors increased by 24 per cent compared with 2 per cent for males. In this age group, men still outnumber women by 54 per cent to 46 per cent — but that ratio will soon reverse.

I fear this gender imbalance is already having a negative effect on the NHS.

The reason is that most female doctors end up working part-time — usually in general practice — and then retire early.

As a result, it is necessary to train two female doctors so they can cover the same amount of work as one full-time colleague.

Given that the cost of training a doctor is at least £500,000, are taxpayers getting the best return on their investment?

There is another important issue. Women in hospital medicine tend to avoid the more demanding specialities which require greater commitment, have more antisocial working hours and include responsibility for management.

nstead of taking on a specialist career, many women prefer to look for a better work-life balance when they have young children of their own.

A section in the GMC’s 2013 report is illuminating. It lists the number of female doctors by speciality for 2012, and shows how many are attracted to general practice rather than other areas of medicine: general practice 29,272; anaesthesia 3,118; paediatrics 2,477; psychiatry 1,778; general medicine 1,054; general surgery 467; trauma and orthopaedics 191.

Compare this with the number of male doctors by speciality, and you can see the huge difference in general surgery as well as trauma and orthopaedics — both of which involve the complex, antisocial hours that deter so many women: general practice 31,711; anaesthesia 6,940; paediatrics 2,578; psychiatry 3,302; general medicine 3,737; general surgery 3,779; trauma and orthopaedics 3,629.

Dame Carol Black, former president of the Royal College of Physicians, pointed out this growing discrepancy in 2004, when she controversially suggested that the feminisation of the medical profession would lead to its degradation.

She said the issue was not whether women doctors could do their job properly, but whether they were willing to devote time and effort, beyond their clinical responsibilities, to activities such as committee work and research.

Politicians are concerned, too. In a Commons debate in June, Anne McIntosh, a Tory MP, said that women doctors who had received expensive medical training but went part-time after starting a family were a huge burden on the NHS.

In reply, Anna Soubry, then a health minister, agreed that they were a drain on resources.
Within hours, after angry responses, some from the British Medical Association and the Royal College of GPs (two professional bodies opposed to any meaningful reform of general practice), Ms Soubry was forced to retract her comment and apologise.

Of course, it is perfectly reasonable that women should have career breaks to have children. But is part-time working on such a large scale in the public interest, even if it is considered perfectly acceptable by our ultra-politically correct NHS management?

GPs are very well paid. Their average salary is around £103,000 — quite sufficient for a woman doctor who is also a mother to be able to afford quality childcare at home.

But the salary also means that part-time working still allows for a comfortable lifestyle.

In addition, doctors tend to marry within their own socio-economic group and, in many cases, the wife is the secondary earner. This also encourages less demanding part-time work.
Isolated

A female junior surgical trainee told me recently that when she went to medical school, some female students announced from the start that they intended to be part-time GPs when they qualified.

But in general practice, part-time working and job-sharing have an effect on patients.

They can deprive them of continuity of care, which is the service they most value. That once key value of the NHS — the cradle-to-grave relationship with patients — has become a thing of the past.

Indeed, I believe that current general practice fails to meet the needs of the modern health service and its patients.

That such a great and growing number of GPs are part-time is a major problem, but it is not the only one.

Because GPs tend to work in small group practices, there is a danger that these can become backwaters, isolated from the nourishing influences of mainstream hospital medicine.

Failure to keep up with the latest developments is a real risk. The perfect solution, suggested by health minister Lord Darzi in 2007, was ‘polyclinics’ — super-surgeries in which GPs and hospital consultants would work together. Sadly the idea was not implemented.

In truth, general practice is organised for the convenience of doctors — particularly, I suspect, for female GPs — and not their patients.

No wonder many people, faced with a medical problem, ignore their local surgery and go straight to A&E — one reason why emergency medical services are at breaking point.
The problems with A&E are very much in the public eye. Not so the issue of part-time working — but it certainly should be, as it is linked.

In the UK we have a serious shortage of medical school places, with the result that more than half of male applicants with the required grades are rejected. As we have seen, many women who take up medical school places subsequently work part-time and, on the whole, tend to avoid A&E.

We make up the shortfall in medical manpower by importing about 40 per cent of the doctors we need. Most now come from austerity-stricken EU countries.

Does this make economic sense?
We need accurate data on the extent of part-time working in order to allow public debate which could then inform medical school selection.

For my part, I believe medical school places should be given to those most likely to repay their debt to society.

Last year (2013) the U.S. businesswoman Sheryl Sandberg published a book called Lean In. It should be compulsory reading for female medical students.

Her thesis is that too few women make it to the top of any profession. She acknowledges the conflict between professional success and domestic fulfilment, but says women should commit more professionally and not ‘lean out’.

How do we persuade female doctors to ‘lean in’? It is a question we urgently need to address.

Gender bias. The one sex change on the NHS that nobody has been talking about

Poor Paediatric workforce planning and career structures

2,000 foreign GPs needed to tackle growing shortage. How about an apology to 20 years of rejected applicants to medical school?

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Desperate situations require desperate measures. Virtual consultations are without evidence, risk GP burnout, errors for patients, and increased litigation costs..

Update 8th November 2017: Huw Pym 2 days ago for the BBC News: Online GP consultation: Opportunity or threat?

NHSreality has told readers that it is going to get worse. The evidence of a fractured system is in front of us all. When I was a trainee GP in Sussex, my Trainer had a weakness: when under time pressure he would not examine patients. The result was the odd error, late diagnosis or mistake. Patients in the 1970s did not expect perfection, and he got away with it, because he knew every patient and their families. Disgruntled patients are much more likely to sue and complain about someone they do not know, as is the case in todays Primary Care.  So over the patients head, on the wall behind them, was a reminder: “Every patient deserves an examination”. This helped him to reflect and to avoid playing to his weakness. Now we have a government encouraging “no examination”. As with telephone triage, all that happens is the demand and expectations will rise. Many GPs tried triage and found they could not live with the increased uncertainty of not examining the patient. Some doctors will take to the change naturally, until they have a complaint and litigation gets involved. Desperate situations may require desperate measures, especially in rural and remote areas without doctors. But virtual consultations risk GP burnout, errors for patients, and increased litigation costs, without any evidence it is any better.. The young and healthy are not the patients who take up most time, but they still deserve an examination.. The Times letters 7th November are correct…. and “simple needs” are what patients should be trained to look after themselves. 

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Chris Smyth reports in The times 6th November: The doctor will see you now: NHS starts smartphone consultations

Millions of NHS patients will be offered the chance to consult family doctors around the clock by smartphone as the first “virtual GP” goes live.

Video consultations are promised within two hours by doctors who say that they are finally bringing the health service into the digital age. However, the project has raised fears among senior GPs that it will create a two-tier NHS, disrupting personal relationships and siphoning off fit, young patients, leaving traditional practices to deal with the frail, elderly and mentally ill.

However, NHS bosses have signed off the scheme, saying that “one size does not fit all” for GP care.

Mobasher Butt, a partner in the “GP at Hand” service, said: “We do everything from grocery shopping to our banking online yet when it comes to our health, it can still take weeks to see a doctor and often means taking time off work. With the NHS making use of this technology, we can put patients in front of a GP within minutes on their phone.”

The scheme involves a deal between an ordinary NHS surgery in Fulham, west London, and Babylon, a technology company that offers a smartphone GP consultation service to private patients.

Like any other NHS GP practice, GP at Hand is paid a flat rate for every patient who is registered with it, but uses the money to sub-contract to Babylon, saying that it will not cost the health service “a penny more” than traditional surgeries.

“I think this is the beginning of the end for the old-fashioned way we use healthcare,” Ali Parsa, founder of Babylon, said. “It’s like going from a Nokia to an iPhone. Maybe next year 10 per cent of people will have one and in five years it will be everybody.” He argued that using a symptom-checking artificial intelligence chatbot and more efficient systems could free GPs from paperwork, allowing them to see patients more quickly. “I think normal NHS GPs will see this works and convert to doing things this way,” he said.

After a pilot scheme involving 3,000 patients, the service is opening to any NHS patient in London who wishes to register. If a patient needs a face-to-face appointment, they must travel to clinics in commuter hubs. The virtual practice has set no limit on how many patients it will accept, saying that this will be guided by how many it can safely treat.

Matt Noble, another of the GP partners, said that the promise of seeing an NHS doctor within two hours at any time would not lead to the service being overwhelmed by minor ailments. “People do value the fact that they can see a GP when they want to, but it doesn’t lead to a massive increase in demand. What it does do is ensure people are seen much quicker,” he said.

Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said that despite benefits for commuters it could make family doctor shortages worse by “luring GPs away” from surgeries.

She said: “We are really worried that schemes like this are creating a twin-track approach to NHS general practice and that patients are being ‘cherry-picked’, which could actually increase the pressures on traditional GPs.”

The service accepts that it is not necessarily suitable for people with dementia, mental health conditions or who are pregnant, but Professor Stokes-Lampard said that these were “the essence of general practice”.

NHS England said: “GP practices are right to carefully test technologies that can improve free NHS services for patients while also freeing staff time.”

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BEHIND THE STORY
This is the second time Ali Parsa has tried to shake up the National Health Service (Chris Smyth writes). He sometimes struggles to hide his frustration with inertia in the NHS and makes no secret of his view that within a few years computers will perform better than doctors at making diagnoses.

Mr Parsa is also undaunted by the experience of Circle Health, the company he founded after leaving finance. Billed as the John Lewis of health because it was half-owned by its staff, Circle became the first private company to take over management of an NHS hospital, Hinchingbrooke in Cambridgeshire.

However, despite positive initial reviews, Mr Parsa was ousted amid disappointing financial results. The hospital was then slated by inspectors before Circle abandoned the contract, saying it was no longer financially viable. Mr Parsa insists that this time it will be different.

Q&A: Don’t smartphone GPs already exist?
Yes, but this is about letting patients make it their main NHS GP.

How can this service offer appointments so quickly?
Babylon says that 40 per cent of queries through the app are dealt with by an AI symptom checker.

Surely some consultations need to be face-to-face?
The service estimates that only about a fifth of problems need a doctor physically present.

How can the NHS afford to do this?
GPs are paid an average of £151 a year for each registered patient but Babylon charges private patients £50 a year.

Can I get this service without switching GPs?
No but Babylon is hoping that demand for it will force other GP practices to strike similar deals.

What about the elderly?
GP at Hand concedes that its service will not be suitable for some patients.

Julia Kellewe on Sunday 2nd August in the Guardian: Dr Now: the smartphone app that puts you in touch with a GP – for a fee – New health apps exploit gaps in overstretched NHS by offering subscribers virtual consultation with a GP

Chris Smyth reports 7th November: Virtual surgeries ‘favour young and generally healthy’

Virtual GPs and consulting by smartphone (Times letters 7th November)

Sir, In your report (Nov 6) on the NHS starting consultation by smartphone, Ali Parsa, the founder of Babylon, says that “this is the beginning of the end for the old-fashioned way we use healthcare”. He hopes that in five years everyone will be consulting by smartphone. This is my idea of a nightmare. Some patients will like a quick call to an anonymous GP but this is likely to increase demand on the NHS from people who would not have sought help in the first place.

Previous research consistently shows that new interventions intended to reduce demand on regular NHS services — such as phone consulting, walk-in clinics and NHS Direct — may be popular with patients but they tend to increase the overall workload. For those who most need the NHS (the elderly, the sick and the mentally ill) the smartphone consultation will be a poor shadow of a personal interaction with a doctor they trust. We should allow Babylon to offer this additional service but we should not imagine that it will ease the demand on NHS services or be a substitute for the type of doctor-patient relationship that people value most.
Martin Roland

Emeritus professor of health services research, University of Cambridge

Sir, “One size does not fit all” for GP care, as your report rightly says. GPs are contractually obliged to accept everyone living within their practice boundary on to their list except in very unusual circumstances. If I were allowed to cherry-pick 3,000 fit and healthy young adults and charge £50 a year I would do very nicely and at the same time improve my golf. However, I do not think I could look local colleagues in the eye who would be left struggling with the complex chronic conditions that are the core business of GPs.
Dr Andrew Holden (GP)

Petersfield, Hants

Sir, The relationship between doctor and patient is essential in clinical practice. Knowledge of clinical history and physical examination of the patient are equally important. Further, a doctor should be able to understand and share the feelings of the patient, which can only be achieved during a consultation in person. How does a smartphone app let a doctor examine a toddler with severe earache?
Dr Sam Banik, FRCPath

London N10

Sir, Providing convenient access to a GP is laudable, and the “GP at Hand” service, via a smartphone app, is something that many patients might love to have. It is worrying, however, that patients will have to transfer their NHS registration from local GP to virtual provider. This could have serious unintended consequences.

The GP at Hand service targets those with simple needs. But needs change: what happens to the person who develops a complex condition or needs in-depth investigations?

Meanwhile, local GP practices will lose the income from those relatively “well” patients, and have to manage a higher ratio of people with complex needs, putting quality in jeopardy.
Don Redding

Director of policy, National Voices, a coalition of 160 health & care charities

Sir, I assume the government will give a grant to those who cannot afford to buy a smartphone. This will be the unemployed and pensioners; the latter are among the most frequent visitors to their GP. Also, such patients will need lessons on how to use a smartphone. Perhaps the NHS will subsidise these costs from the money that it will save.
Thea Valman

London NW11

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Scottish Medical Student numbers – cannot afford to fall further

For a country of 6m people, Scotland has always been over supplied with medical student places, and has no fewer than 5 medical schools where Wales has only 1. If they were all the same size, Scotland would have over twice the capacity… Scotland has a history of leading in medicine, and exporting it’s graduates around the world, so in hard financial times a fall of 12% is surely sensible. It has been “batting above its average” for years. The names, pictures and list are here.. It would be much more sensible to aim at overcapacity, and exporting some 10% of doctors in future.

Kevan Christie in the Scotmas, 31st October 2017 reports: Number of Scottish students studying medicine falls as lack of GPs

The number of Scottish-domiciled medical students has gone down by 12 per cent since 2000 as the country reels from a chronic shortage of GPs. Figures obtained by The Scotsman show that in 1999-2000 the percentage of Scots students studying clinical medicine in the country was 63 per cent – this has now dropped to 51 per cent despite the overall numbers of medical students increasing significantly. Research has shown that medical students on the whole choose to practise in their country of origin once they graduate but a higher proportion of university places are being taken by would-be doctors from England, the EU and the rest of the world..

This means homegrown students are losing out on places when there is a projected deficit of 828 GPs needed in Scotland by 2021. As of last year 2,275 out of 4,455 medical students are Scottish….

The article goes on to explain that there is a new graduate entry medical school (10 years behind England and Wales, but welcome nevertheless) which should mean that the bias towards women may be corrected slightly.

 

 

A loss of personal continuing care. 700 practices in 5 years. Is the GP going the way of the Dodo in the past, or the Salmon in the future? We need to rediscover it’s value.

GP numbers are falling (Trends in the NHS) , and over 700 practices have closed in the last 5 years. This means that list sizes are rising. This information dates to 2015, so is 2 years out of date. The rationing of places at Medical School, over 30 years and 8 administrations is to blame, along with poor selection age.

An example of a table of data is from Wales: 

In Wales there are 454 Practices, which consist of 1663 GPs, 334 other GPs (assistants), 3,187,000 patients, 7021 average patients per practice, and a residential population 3,099,000. This gives an average population per practice of 6826.

There are several issued hidden in these figures. There are more patients registered with Welsh GPs than there is population in Wales. This is because of the border issues, where patients in Wales get free prescriptions, but those eligible in England pay. There are many more part time GPs than there were 10 years ago. The figures, in rough terms, just have to be multiplied by 20 for England, and by 2+ for Scotland as the whole UK is under doctored.

The number of GPs up to 2011 is shown here (Nuffield Trust), but is of course 6 years out of date.. It is interesting that even professional reporters cannot find up to date comparison figures from the UK Regions to compare with England, and this emphasises that we have no “National” in our health services. There have however been consistently more GPs in Scotland

Another problem is the definition of a GP. WONCA had a go in 2005. Many different countries have many different interpretations. In the UK he has to be “Competent and Capable” (RCGP), able to work “Independently” and traditionally to provide continuity of care for families. This “cradle to grave” image is fast disappearing, and the reality of part time GPs who may not know their patients has to be faced. Is the GP going the way of the Dodo in the past, or the Salmon in the future?

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Laura Donelly and Patrick Scott reports in the Telegraph 16th October 2017: Rise of the ‘super-size’ GP surgery as quarter of practices now deal with more than 10,000 patients

New figures reveal the rise of the “supersize” GP surgery, amid the closure of almost 700 practices in five years.

Family doctors said they were being forced to handle far more cases than they could cope with, with one in four practices now seeing more than 10,000 patients.

The proportion of surgeries with such list sizes has risen by 27 per cent since 2013, the NHS data shows.

It follows admissions from the Health Secretary that the traditional family doctor role has been eroded by decades of underfunding.

Jeremy Hunt told a conference on Thursday that the “magic” of general practice was under threat, with GPs burned out and left feeling “stuck on a hamster wheel” with up to 40 patients to see daily.

The statistics from NHS Digital show that 28 per cent of GP practices in England have a list size of at least 10,000 patients – including some with more than 20,000 cases on their books.

Professor Helen Stokes-Lampard, chairman of the Royal College of GPs, said family doctors were left overloaded, and too often unable to meet the needs of their patients.

It follows admissions from the Health Secretary that the traditional family doctor role has been eroded by decades of underfunding.

Jeremy Hunt told a conference on Thursday that the “magic” of general practice was under threat, with GPs burned out and left feeling “stuck on a hamster wheel” with up to 40 patients to see daily.

The statistics from NHS Digital show that 28 per cent of GP practices in England have a list size of at least 10,000 patients – including some withmore than 20,000 cases on their books.

Professor Helen Stokes-Lampard, chairman of the Royal College of GPs, said family doctors were left overloaded, and too often unable to meet the needs of their patients.

She said: “The phenomenon of growing patient numbers, and a lack of GPs to deal with growing demand is a long-running trend, and something the College has been drawing attention to for many years.

“As a result, many GP practices are seeing escalating patient lists they they simply can’t deal with – although we must recognise that sometimes increasing list numbers are due to practices merging and pooling their resources,” she said.

Prof Stokes-Lampard said there was a desperate need for more GPs and practice staff.

Dr Richard Vautrey, GP committee chairman said doctors were struggling to cope with an extra 2.6 million patients registering in the last four years, while funding and staffing levels had not kept pace.

“GP services are struggling to cope with unsustainable workload and deliver the care their local communities need,” he said.

A recent BMA survey found that more than half of GP practices were considering closing their patient lists as they could no longer provide safe care to the public.

The figures show the total number of practices registered with a GP has risen from 56.2m to 58.7m in five years. Meanwhile the number of practices fell from 8,032 to 7,358.

Of those, 2,082 have more than 10,000 patients on their books – including 157 with more than 20,000 patients.

On Thursday Mr Hunt said many GPs were at the ‘end of their tether’ and dropping out of the profession. He said: “Too many of the GPs I meet are knackered, they are often feeling at the end of their tether.

“They feel that they’re on a hamster wheel of 10 minute appointments, 30 to 40 every day, seem never ending.

“They don’t feel able to give the care that they would like to to their patients and increasing numbers of them are choosing to work part-time and at worst to leave the profession.

“We have to think really hard about how to stop that happening if we’re going to use the magic of general practice to do what we need it to do for the NHS.”

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The decline of General Practice.. Bribes may be too late…

Update 24th October.

Tara Russell in the Daily Echo reports: GPs to be given £20,000 ‘golden hello’ for working at the coast or countryside.   

and the BMJ Zosia Kmietowicz reports: “Golden hello” of £20 000 to be offered to 200 GPs a year, says health secretary

There will be many post mortems once the old fashioned GP has disappeared, but it is not only about numbers, but also about experience and reduction of waste. A good GP reduces unnecessary referrals and investigations, lives with uncertainty and is trusted to use time as a diagnostic tool. 20 years ago most countries envied our primary care GP system of gatekeepers, but we have steadily destroyed it. In Folkestone, (and many other places) the population is in dire need. The goose that laid the golden egg for efficiency has gone… Perhaps readers should ask their MPs 1: “Why have 9 out of 11 applicants for Medicine been rejected for 30 years, when we continue to import so many doctors from overseas? 2: “Why are 80% of Medical students women, and should this be addressed by graduate entry, or adverse selection. The answers are short termism and rationing.

In the last week I have heard and witnessed two stories close to me. A citizen had renal colic and was getting  better when seen at home. After 8 hours in Casualty, an USS, a CAT scan and bloods as well as urine dip test (not available to the paramedic visiting) he was sent home. The other was a case of acute orchitis who had 3 courses of antibiotics, investigations ++ and 6 consultations in A&E and GP. An experienced GP would have dealt with both these cases much more efficiently.

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Shane Brennan interviews Dr for the Daily Post 19th September 2017: The North Wales doctors surgery … with no doctors

Reliance on locums since GPs retired means some days there are four available, but some days only nurses

Nurses are having to stand in for GPs at a surgery where on some days there are no doctors available to see patients.
The Pen y Maes medical centre in Wrexham is being run by Betsi Cadwaladr since its doctors retired last year.

The health board has had to draft locum GPs in to do the work, but according to local councillors and patients, on some days there are none available.
Fed up patients are now planning a protest to voice their frustrations with health board bosses, who say they are looking to recruit GPs to take over the practice.
Councillor Gwenfair Jones, who represents Gwersyllt West – one of the wards hit by the problems at the surgery – said: “Despite repeated requests we are not getting the service that we deserve, a total reliance on locums means that some days there are four GPs other days there are none.”

She added: “The Health Board is meeting this Thursday at 10am at the Catrin Finch Centre at Glyndwr and we will be there to give them a warm welcome and to make sure patient’s voices are heard”
Dr Sophie Quinney from campaign group GP Survival (Wales) welcomed the protest, she said: “Patients are absolutely right to be concerned by the direction of travel for primary care across North Wales. It is well accepted that surgeries run by family doctors are more cost effective and for the most part deliver a superior service to those run by administrators.
“Sadly, Welsh Government has offered too little too late by way of funding and resources to help ease the ever-increasing burden on these doctors, and they are voting with their feet.

“What is urgently needed is dialogue between GPs and their patients, so that the public can get behind this important cause and exert the type of pressure that is needed to turn this sorry situation around.”

A spokesman for Betsi Cadwaladr University Health Board said the board was trying to find a solution that would see full time doctors take over at the practice.

He said: “We remain committed to providing a high quality service at Pen y Maes, which includes working to fill vacant posts at the practice. We are actively looking to fill vacant salaried GP positions at the practice, and will be interviewing for Advanced Nurse Practitioner posts next week.

“We continue to work hard to develop a plan for the long-term future and success of the practice, and apologise for any difficulties patients have had in booking appointments.”
A Welsh Government spokesman said: “We expect all Health Boards to provide primary care services which meet the needs of their populations. Investment in general medical service has increased by approximately £27m as a result of the agreed changes to the GP contract for 2017/18. This provides a strong platform for GPs to continue to provide high quality, sustainable health care across Wales.”

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Reasons behind the decline (Letters in The Times 14th October 2017)

Sir, You report that Jeremy Hunt is proposing to pay golden hellos to a limited number of younger doctors (“GPs offered £20,000 bonus to stay in neglected areas”, Oct 12), and that GPs who know patients personally are at risk of dying out (Oct 13).

I retired from my general practice in 2015 at 57 but carried on working as a locum until October last year because I did not feel ready to stop doing the job that I had previously enjoyed for most of my career.

Before my eventual retirement I had worked as a “family doctor” for 30 years in the same practice. I have never been afraid of hard work and many of my patients will remember the days when doctors were called out from home or would visit out of hours. But towards the end the pressure of the “day job” was starting to affect my health and was putting me at risk of “burn out”. I was also spending not much more than 50 per cent of my time in “real” patient contact.

To the many patients who would ask why I was retiring early, I would reply that the problems of general practice go back at least ten years, with governments of all political persuasions failing to listen to GPs. I would often say that the failure to listen to GPs went back as far as Tony Blair’s government, if not before that.

Although the government is beginning to make some belated proposals to improve GP recruitment I can also only guess how many GPs of my age and experience have been lost to the profession because of the inaction of successive governments.
Dr A G Bennett

Leek, Staffs

Sir, For a brief moment after the GP contract of 2004 was implemented GPs felt valued, but then the attacks began: an onslaught of criticism, started by Labour and continued by the Conservatives. It felt like a strategy: an intention to demoralise GPs. If so it worked, as general practice is now in crisis, with problems with recruitment and retention. And yet the health secretary states that GPs are the heart and soul of the NHS — if general practice fails, the NHS fails. What on earth was the GP bashing of the past 13 years all about?
Dr Bruce Halliday

Dumfries

GP practices close in record numbers – Wrexham patients protest about GP staffing levels. This is only the beginning….

Just cry at the bribery, and the Death of the Goose that used to lay the golden eggs that used to make the Health Service(s) so efficient, and the envy of the world.

How to kill the goose and create a shortage of 10,000 GPs – Patients kept waiting as new doctors shun GP jobs

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Hands up – who want’s to be a GP today? Recruitment is at an all time low despite rejecting 9 out of 11 applicants for the last few decades..

 

Jeremy Hunt to unveil state-backed GP indemnity deal. Bribery is an admission of perverse recruitment and education processes..

GPonline reports 12th October (Jeremy Bostock): Jeremy Hunt to unveil state-backed GP indemnity deal

Health secretary Jeremy Hunt will reveal plans for a ‘state-backed scheme for clinical negligence indemnity for general practice’ at the RCGP annual conference in Liverpool on Thursday.

This “Bribery” is an admission of perverse recruitment and education processes over many administrations. Rationing of training places and recruiting from overseas 6 years later….

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The anxiety about indemnity is evident in GP Frontline – Raging against the rising costs of medical indemnity (Author unknown) ,and in numerous recent publications.

Anu Patel on 23rd March: Indemnity: Rising indemnity costs are a threat to general practice

David Millett on 9th October: Thousands of GPs urged to write to MPs about indemnity

It is no wonder that bribes have been offered, and in Wlaes this has helped fill some GP Training posts, but as predicted, England has, in a competitive market, offered to march the inducement fees of £20K.

Alex Matthews-King in March Pulse: £20,000 GP ‘golden handshake’ scheme to be expanded this year

BBC News today 12th October: Jeremy Hunt to pledge £20,000 ‘golden hello’ for rural GPs

Newly-qualified GPs are to be offered a one-off payment of £20,000 if they start their careers in areas that struggle to attract family doctors.

The £4m scheme, to be announced by Health Secretary Jeremy Hunt, aims to boost the numbers of doctors in rural and coastal areas of England.

Mr Hunt will also pledge to “secure general practice for the future”.

The Royal College of GPs backed the plan saying there is a “serious shortage” of family doctors.

The one-off payment will be offered to 200 GPs from 2018.

As of September 2016, there were 41,985 GPs in England.

Mr Hunt is due to speak at the Royal College of GPs’ annual conference in Liverpool, where he will offer something for those already in the profession too, by announcing plans for flexible working for older doctors – to encourage them to put off retirement.

He will also confirm plans for an overseas recruitment office which will aim to attract GPs from countries outside Europe to work in England.

“By introducing targeted support for vulnerable areas and tackling head-on critical issues such as higher indemnity fees and the recruitment and retention of more doctors, we can strengthen and secure general practice for the future,” the health secretary will say.

The Royal College of GPs said the package must be delivered in full and welcomed the commitment to incentivise working in remote and rural areas.

NHS England has already pledged an extra £2.4bn a year for general practice in England – part of which will fund plans for 5,000 extra GPs by 2020.

But Dr Richard Vautrey, chairman of the British Medical Association’s GP committee, said the government was not on course to reach that target.

“General practice is facing unprecedented pressure from rising workload, stagnating budgets and a workforce crisis,” he said.

“‘Golden hellos’ are not a new idea and unlikely to solve the overall workforce crisis given we are failing badly to train enough GPs to meet current demands.”

In 2016, the BBC learned that there were some practices in England offering a bonus of up to £10,000 to attract new doctors.

But The Nuffield Trust think tank said recruitment was “only half the battle”.

“The NHS is struggling to hang on to qualified GPs, with surveys showing 56% plan to retire or leave practice early. Many trainees also drop out when they finish,” said senior policy fellow Rebecca Rosen.

300 Med Student dropouts, out of 6000 – 5%

Medicine is a course which involves determination and resourcefulness. Shrinking violets find it difficult and the pure memory work at the beginning puts off some intelligent students who would like a more cerebral approach. Problem Based Learning courses are different, and more and more students are learning this way, especially in fast track graduate entry courses. Adult learning, where one is self sufficient, addresses and understands, and looks up learning needs, is the method preferred. Unfortunately undergraduate entry has less mature students. It also has 80% bias to women, so presumably more women than men drop out. It would be interesting to know the ratios for acceptances: dropouts for each sex at undergraduate and at graduate level. Why not let all who reach a certain standard and wish to do medicine do so? Overcapacity will ensure we do not have to import doctors, and since only 2 out of 11 applicants are successful we know there is potential for a lot more.

Sian Griffiths and Jonathan Corke report in the Sunday Times August 27th: 300 student doctors quit university each year

An ‘epidemic’ of mental health problems is being blamed as a large number of would-be medics fail to complete their degrees

Nearly 1,600 of Britain’s brightest students have been asked to leave medical degrees or have dropped out in the past five years, costing the taxpayer millions.
Data from more than 30 medical schools, released under freedom of information laws, reveals that nearly 1,200 British students, most with top grades at A-level, left with no qualification. Others changed course or were awarded a BSc.
One expert spoke of an “epidemic” of mental health problems among students and said more support was needed. Another, Alan Smithers, professor of education at Buckingham University, said: “This level of attrition is a terrible waste of public money as well as being desperately sad for the individuals concerned.”
It costs about £250,000 to train a doctor and gaining a place on a degree course is ferociously competitive. Experts were concerned by the figures, particularly as NHS England has launched an overseas recruitment drive for 2,000 doctors to plug gaps in GP surgeries.
Professor Les Ebdon, head of the Office for Fair Access, which regulates access to higher education in England, said: “Obviously it would be better to help our British students become doctors . . . We cannot keep relying on other countries.”

More than one in 10 students failed to become doctors on some courses. At Leicester University the figure was 37 out of the cohort of 240 (15%) who started in 2011-12. Richard Holland, head of the medical school (elect) at Leicester, said completion rates were improving. The University of East Anglia said its drop-out rate for undergraduate medicine was 8.5%. By contrast, just five students at Swansea failed to complete the course.

The General Medical Council, which regulates doctors’ training, cited an attrition rate from all medical degrees of 1.8% in 2014 but is understood to be working on new figures. Some medical schools said they had seen a rise in mental ill health. “There is an epidemic among young people of mental health problems and it requires much greater support from universities,” Ebdon said.

Hannah Overton, 22, who attended a state school in Ipswich, was accepted at University College London (UCL) to study medicine two years ago. She left after being diagnosed with a mental health condition and says she did not receive adequate support to qualify as a doctor. She is now a midwife’s assistant.

She said: “There is a very old-fashioned attitude in medical schools that you are weak if you have a mental health issue. It broke my parents’ hearts.”

Professor Deborah Gill, medical school director at UCL, said: “We are sorry Hannah felt she lacked support and would be happy to speak to her if she feels this would help other students.”

@siangriffiths6

and in the Sunday Times 3rd September the letters:

CARE FOR DOCTORS’ MENTAL HEALTH
There is a history of higher rates of psychiatric problems in the medical profession (“3O0 student doctors quit a year”, News, last week). However, understanding of mental health conditions has been boosted via social media and other outlets supporting medics’ mental health, the majority of which are not “official” and are peer-led, such as Nightline and MedSocs as well as Twitter.

Perhaps now more doctors and medical students are publicly seeking help. Recent data suggests one in four doctors have experienced suicidal thoughts, yet only one in five are diagnosed with clinical depression. Some of the best doctors I know are peers who have struggled with, taken responsibility for and ultimately improved their own mental health.

To make a difference, universities need to challenge expectations, fund services and normalise talking about the subject. Progress is inhibited by a public discourse that sees young doctors’ mental health struggles merely as a financial penalty for the taxpayer, rather than a public health issue that requires care and investment to solve. This attitude was prevalent in your article, which discussed the need for a “recruitment drive” to fill the gaps of those who did not complete their courses, rather than the lack of official support available.
Dr Sarah Simons, Nottingham

Image result for student dropouts cartoon

Medical Schools: your chances – applications-to-acceptance ratio was 11.2.

BBC News 4th October 2016: The number of medical school places will increase by 25% from 2018 under plans to make England “self-sufficient” in training doctors.

The government’s plan will see an expansion in training places from 6,000 to 7,500 a year.