Overseas doctors taken to solve the short term problem of under-capacity. The long term perverse outcomes are expensive and threatening!

Our politicians have let us down. The equivalent of a “fire sale” of properties is the recruitment of overseas trained doctors. Their communication and cultural issues will, we know largely persist. They will generate more complaints and litigation, and they will be established when our own universities are able to train enough doctors for the future. This will mean more emigration, and the cycle of boom and bust will continue will continue…. unless we have a political system that fosters open debate and long term planning with altruistic leaders who see further than 4 years ahead. Overseas doctors are recruited to solve the short term problem of under-capacity. The long term perverse outcomes are expensive and threatening! Litigation, complaints and falling standards, and our own trainees are treated so much better abroad that they often choose top stay. The on line comments and the letters add well to the debate, but none mentions our failing political system..
Matt Dathan , Home Affairs Editor for The Times 7th April 2023: NHS hires more foreign doctors than total medical school intake
Ministers have been urged to boost medical school places after figures revealed that more foreign doctors joined the NHS last year than the number of medical students who enrolled on courses. Foreign citizens made up 46 per cent of all doctors joining the NHS in England in 2022, according to the latest healthcare workforce statistics. A total of 12,148 doctors joined from abroad compared with 13,516 British doctors last year. The vast majority of those recruited from overseas — 10,193 — were from outside the European Union.
Research by the think tank Migration Watch UK found that the total of foreign doctors was 73 per cent higher than the number of British students who enrolled to train as doctors in England’s medical schools in 2022-23.

In the same year, universities rejected 10,000 medical school applicants owing to the government’s strict cap on funding. Many applicants had achieved the necessary grades and the need for trainees is estimated at between 5,000 and 11,000 more a year.
Medical school places are capped in each part of the UK with “intake targets” used to limit recruitment in light of the significant specialist resources and staffing that courses require. In England, places are capped at about 7,500 a year. The increasing numbers of overseas recruits compared with the sluggish pace of medical school enrolments suggests that within the next few years, the majority of new doctors joining the NHS will come from outside the UK. Migration Watch UK, which campaigns for lower levels of immigration, said this will diminish Britain’s self- sufficiency and leave the country reliant on recruitment from overseas.

To halt the trend, it has recommended the government increases medical training places available to British students in the next academic year by 1,500 places with a funding boost of about £427 million. This would return funding to 2021-22 levels, the highest since the Conservatives entered government, when 7,690 students enrolled on medical courses in England. Jeremy Hutton, from Migration Watch UK, said the government needed to act to halt the growing dependency on foreign doctors. He said: “That the government has failed to increase the number of funded training places while demand has grown is nothing short of a dereliction of duty.
“It is one thing to recruit foreign doctors to fill short-term needs, it is another to rely on them long-term instead of training up future doctors here in Britain, and now we’re hiring more doctors from overseas than we’re even bothering to train.”
The Department of Health and Social Care said: “There are now record numbers of doctors working in the NHS and we will publish a long-term workforce plan shortly to help recruit and retain more staff. “We have funded 1,500 more medical school places each year for domestic students in England — a 25 per cent increase over three years — and delivered five new medical schools. “The vast majority of doctors trained in the UK do go on to work in the NHS, with more than 94 per cent using their medical qualification within the UK.”

Stuart Smith: This has been going on for years. Hold back first class school leavers so we can buy in cheaper doctors from overseas. Another policy to reject our children. Unaffordable housing, worse pensions, graduate taxes, unaffordable student accommodation, higher cost of living. And they wonder why UK productivity is going down the drain.
Martin Rimmer: Yes, in my daughter’s A level year several of her peers went on to get 3 A* but failed to get an offer from a medical school. My brother only managed to get an offer after an invention from his uncle. It seems it has always been like this. Robbing the the 3rd world of their medical professionals when we should be training our own. Here I am in France and almost every medical professional is trained in France. The UK, as in many other areas, is completely broken.
Andrew Rowe: Agree, immoral actions. We don’t invest enough in our young people, but buy cheaply already trained doctors from abroad, removing them from their own countries that need them.
Paul Kelly: How about encouraging Junior doctors to stay? Of course that would mean paying them properly. Seems to me they are trawling the Indian subcontinent for cheap labour.
Peter Weyers: The UK parasitises on the training costs incurred by other countries, often developing countries that desperately need these people themselves. Sunak runs a tough anti-migrant campaign while simultaneously sucking poor countries out of their highly skilled workforce.
Drew Clark: In the UK, there are huge numbers of students with top grades who struggle to get into medical school. It’s outrageous! They have to increase the number of medical places at universities by 50%+. The NHS is broken right now, and they need to start this immediately so the number of doctors filtering into the NHS can increase hugely in 5-10 years time
Eddie Bowers: Apparently school leavers with top grades struggle to find places in medical school, this can only be down to limited resources i.e. not a shortage of quality applicants. Why?
HRichards: Some of it’s down to the lack of places in medical schools initiated by Blair many years ago – something many Labour supporters seem to have forgotten. I don’t know what the attrition rate is for Junior doctors but I believe the root cause is the working conditions.
Galaxian: Totally wrong on every level. Importing foreign doctors trained in substandard settings under corrupt systems outsude the EU. When compared to NHS investment in medical education and training it’s no surprise we have medical negligence claims at an unacceptable level. Invest in more UK places and end this false economy.
T Jawed: Consecutive governments have decided that it is more cost efficient to recruit doctors from abroad rather than train our own, as a result many straight A students cannot get on a medical course unless they go abroad to Hungary or Bulgaria and three of the most recent medical schools to open in the UK will only take foreign applicants. The Government have let down the NHS and our excellent students who aspire to be doctors…..

The Times letters 8th April 2023: Mounting concerns over junior doctors’ strike. Sir, Junior doctors are struggling to cope with their workload, not least because of falling job satisfaction caused by an impaired ability to offer the best care. However, with their decision to strike they appear to have lost sight of the virtues that define the good doctor: empathy, compassion, altruism and integrity (“Strike to ‘overwhelm’ A&E”, Apr 7). Barely a day goes by without reports of the harm patients are experiencing. This can only get worse with more strikes. Confronted with the suffering of an individual patient, a doctor cannot fail to be moved by their plight. Yet, when faced with a population of similar nameless patients it is all too easy for the same doctor to become inured to the harm that is being done by their action. I urge junior doctors and the BMA to reconsider their decision and prevent any further harm being done to patients by their actions.

The NHS has thrived on the mutual respect and trust between doctors and patients. Once lost these are not easily regained.
Dr Stuart Calder
Clinical ethicist, York

Sir, I have been an NHS hospital doctor for 34 years and there is no doubt that morale is at an all-time low. If the service is not to decay further, with an even bigger exodus of staff, the government needs to pay doctors what we are worth. The NHS is a fine institution but an increasingly intolerable employer. Rather than focusing on a “takeover” of the BMA, your report (“Junior doctors strike: How a Reddit rebellion took over the British Medical Association”, Mar 31) should have reflected on whether any other group would tolerate such a massive decrease in pay. It seems easy enough for this government to find the money to bail out banks or pay their cronies a small fortune for dodgy PPE contracts, so it should be able to find some to settle this dispute with junior doctors, and the one to follow with consultants.
Simon Cole
Consultant surgeon, Abingdon, Oxon

Sir, Many UK medical schools have resurrected versions of the Hippocratic Oath. At Bristol University, medical students took responsibility for writing the “Bristol Promise”. This ends: “I will work for the good of all persons whose health may be placed in my care and for the public wellbeing.” It is a magnificent piece of theatre when the students stand during their graduation ceremony to recite their promise. Sadly, for some of today’s young doctors, that is as far as it goes.
Gareth Williams, MD, FRCP
Former dean of medicine, Bristol University; Rockhampton, Glos

Sir, You report that more overseas doctors than the entire UK medical school intake were employed by the NHS last year and at the same time we maintain a ludicrous cap on medical school places of 7,500 per year (“NHS figures reveal growing reliance on overseas doctors”, Apr 7). When will the government realise that only by acting now will we address problems five years hence? Increasing places does not necessarily equate to huge cost increases as there are ways of mitigating costs, including shortening the courses, changing the entry requirements (at present ridiculously stringent) and slowing the retirements of experienced teachers and trainers. Further, and leaving aside discussions on immigration, the continued drain on other countries’ health systems to run our own is immoral.
Chris Wilson
Surgeon, Cardiff

NHSreality posts on the manpower crisis and lack of planning: oncoming since 2000

What’s happened to NHS spending and staffing in the past 25 years?

Some 25 years ago, if there had been a conference of Health Ministers from all around the world, the one thing in the UK that all would have been jealous of would have been Primary Care. The efficiency of seeing 90% of the demand for 10% of the budget made the 1990s NHS (before devolution and the purchaser provider split) the envy of the world. The 2020 Olympics revealed to the profession and those in the know exactly how degraded we were: the irony of the opening ceremony was lost on the public at large, but evident to all professionals.
The decline in numbers of GPs, and limitation of medical student places because we could recruit easily from overseas was driven by financial and short term political considerations. This would have been far less likely in a country with any form of proportional representation, because without the threatening whips to subdue their dissenting MPs, an “honest debate”, as requested by Mr Stevens, cannot happen. The slow burn of a collusion of political denial and a public willing to believe they can have everything for everyone everywhere for ever for free (suspending their belief in reality) has led here.
Following several reports the profession has not been involved enough in management or strategy. Indeed, GPs were excluded from these areas for many years. The waste of employing administrators (wrongly named managers – because the latter initiate change) to oversee the purchaser provider split needs to be addressed, and abandonment of this split to happen rapidly. A fair 4 health services might still be beyond us, but at least we can try.
If recruitment and training remain devolved, only leaving the European Convention of Human Rights can ensure that doctors trained in one dispensation do not leave without paying back their fees. Too few doctors are in the pipeline for a decade, and they will gravitate to the richer and more affluent areas with better schooling etc unless we are open to large sticks and carrots.

Re: What’s happened to NHS spending and staffing in the past 25 years? BMJ 2023;380:p564
Ministers are often heard referring to increases in NHS spending and staffing—but what’s the true picture behind those numbers? John Appleby finds some interesting stories in his analysis of the data from England over time and with demographic change
Twenty five years ago, in the financial year 1998-99, the Department of Health in England spent £36.6bn in total, equivalent to £59bn in 2021-22 prices. The bulk of this covered the NHS but also included public health, arm’s length health bodies, and other health services. Today, in 2022-23, the department’s planned spending (excluding special covid spending) is likely to be around £165bn in 2021-22 prices, a real terms increase of 180%.

On average, this has meant health spending growing at a rate of around 4.4% each year since 1998-99. Not bad, and the sort of growth that should cover things such as population growth and demographic change, technological change, and improvements in care quality.

But growth in spending has not been an even 4.4% a year (fig 1).1 Even when adjusted for changes in the population and its demographic structure, it’s clear that the bulk of the increase in spending happened between 1998 and 2009 (by 6% a year). Between 2009-10 and 2019-20 average annual growth was just 0.4%.

Unsurprisingly, trends in health staff numbers more or less match spending trends. Between 1998 and 2022 the number of full time equivalent NHS and general practice staff grew by 62%, from 853 641 to 1 381 439. But this growth has been uneven: an increase of 29% between 1998 and 2005 was followed by a 1% decrease between 2005 and 2013, and then an increase again of 26% to 2022 (fig 2).2345

Two key trends

Relative to the population of England over these three periods, total NHS plus general practice staff per head rose by 25%, fell by 7%, then rose again by 19%. If the figures are adjusted, as with spending, to take account of the change in England’s demography over the past 25 years, then the current rate in 2022 has more or less recovered to that in 2005, from a low in 2013 (fig 2).

Understanding trends in different staff groups is hampered by the fact that there have been many changes in definition and data collection systems over the years. Fig 3 shows the main trends in NHS and general practice staffing numbers, together with some of the more significant breaks in the data.2345

Two trends worth noting are the large and consistent growth in the number of consultants—a rise of 163% over the past 25 years—and the rise and fall in qualified GPs. Since 2015 the number of qualified GPs (partners and salaried) has fallen by 7%, equivalent to 1900 GPs.

One lesson from these historical trends might be that healthcare could be in a better position now if spending had grown more consistently over time and across staff groups, allowing the workforce to grow in line with population change and to be able to deliver a better quality service.

Feature Data Briefing

What’s happened to NHS spending and staffing in the past 25 years?

BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p564 (Published 15 March 2023)Cite this as: BMJ 2023;380:p564

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1. John Appleby, director of research and chief economist
2. john.appleby@nuffieldtrust.org.uk

Ministers are often heard referring to increases in NHS spending and staffing—but what’s the true picture behind those numbers? John Appleby finds some interesting stories in his analysis of the data from England over time and with demographic change

Twenty five years ago, in the financial year 1998-99, the Department of Health in England spent £36.6bn in total, equivalent to £59bn in 2021-22 prices. The bulk of this covered the NHS but also included public health, arm’s length health bodies, and other health services. Today, in 2022-23, the department’s planned spending (excluding special covid spending) is likely to be around £165bn in 2021-22 prices, a real terms increase of 180%.

On average, this has meant health spending growing at a rate of around 4.4% each year since 1998-99. Not bad, and the sort of growth that should cover things such as population growth and demographic change, technological change, and improvements in care quality.

But growth in spending has not been an even 4.4% a year (fig 1).1 Even when adjusted for changes in the population and its demographic structure, it’s clear that the bulk of the increase in spending happened between 1998 and 2009 (by 6% a year). Between 2009-10 and 2019-20 average annual growth was just 0.4%.

Fig 1

Change in total health department spending since 1998-99 (excluding covid-19 measures), England, at 2021-22 prices

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Unsurprisingly, trends in health staff numbers more or less match spending trends. Between 1998 and 2022 the number of full time equivalent NHS and general practice staff grew by 62%, from 853 641 to 1 381 439. But this growth has been uneven: an increase of 29% between 1998 and 2005 was followed by a 1% decrease between 2005 and 2013, and then an increase again of 26% to 2022 (fig 2).2345

Fig 2

Change in total number of NHS and general practice staff since 1998-99, England

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Two key trends

Relative to the population of England over these three periods, total NHS plus general practice staff per head rose by 25%, fell by 7%, then rose again by 19%. If the figures are adjusted, as with spending, to take account of the change in England’s demography over the past 25 years, then the current rate in 2022 has more or less recovered to that in 2005, from a low in 2013 (fig 2).

Understanding trends in different staff groups is hampered by the fact that there have been many changes in definition and data collection systems over the years. Fig 3 shows the main trends in NHS and general practice staffing numbers, together with some of the more significant breaks in the data.2345

Fig 3

Trends in NHS staff numbers by professional group, England, since 1998-99

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Two trends worth noting are the large and consistent growth in the number of consultants—a rise of 163% over the past 25 years—and the rise and fall in qualified GPs. Since 2015 the number of qualified GPs (partners and salaried) has fallen by 7%, equivalent to 1900 GPs.

One lesson from these historical trends might be that healthcare could be in a better position now if spending had grown more consistently over time and across staff groups, allowing the workforce to grow in line with population change and to be able to deliver a better quality service.

Footnotes

• Competing interests: I have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.
• Commissioning and peer review: Commissioned; externally peer reviewed.

References

1. ↵Appleby J, Gainsbury S. The past, present and future of government spending on the NHS. Nuffield Trust. 2022. https://www.nuffieldtrust.org.uk/news-item/the-past-present-and-future-of-government-spending-on-the-nhs.
2. ↵NHS Digital. NHS staff: 1998-2008 Medical and dental. https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics-medical-and-dental-staff/nhs-staff-1998-2008-medical-and-dental.
3. ↵NHS Digital. General practice workforce, 30 September 2022. 2022. https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/30-september-2022.
4. ↵NHS Digital. General and Personal Medical Services, England—2004-2014, as at 30 September. 2015. https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/2004-2014-as-at-30-september.
5. ↵NHS Digital. NHS workforce statistics—October 2022. 2023. https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics/october-2022.

Responses: Dear Editor
This article was a very interesting read. It’s a shame the author, John Appleby, did not also represent the number of NHS managers in figure 3 of the data analysis. This would have given Figure 1 more context.
We know the number of managers in the NHS has increased in 25 years and alongside clinical staff representation of this would have been important in the understanding of the cost of delivering healthcare, especially in the current climate when clinical staff are the ones needing to strike for better pay and conditions

NHSreality posts on manpower planning (or lack of it)

What is the profession thinking….. and feeling while drowning?

GPs are drowning in a leaking boat with bricks being thrown at us (see below). NHS consultants are to be balloted over potential strike action. Press releases by NHS England (they don’t apply to the whole) are prescriptive: Consultants to sign new NHS contracts & Future consultants to be tied to NHS. The Guardian is clear, and closest to the feelings, as most doctors are “liberals” (non political): Pension pot offer won’t fix NHS workforce crisis. We already have means tested social care, and dental care, so why not extend the system to health. In this workforce crisis politicians could give tax relief for Private Medical Insurance and private payments, until the long term effects of political denial and collusion with unreality have been addressed. Means tested co-payments for health care would be progressive, but to ensure a sustainable fair & universal system fit for the future, we need to learn and choose from EU and Australasian system models.

Alice Barber in the BMJ?: A front row seat for the exodus—is the NHS crisis scaring medical students away? BMJ 2023;380:p525
Over the past year, I and many other medical students have witnessed a growing number of doctors and other healthcare professionals leaving the NHS. This is supported by wider data. A survey of 4553 junior doctors by the British Medical Association found that four in 10 junior doctors plan to leave the NHS as soon as they are able to find another job.1 Similarly, a survey of almost 8000 doctors found that four in 10 consultants plan to leave or have a break from working in the NHS over the next year.2 Although these numbers reflect those intending to leave, there is evidence that doctors are following through on this intent, with a record number of NHS workers taking retirement in April 2022.3 Workforce data also indicate the scale of the problem in general practice, with the equivalent of 279 full time GPs leaving in one year alone, 91 of whom left in January 2022.4 These numbers show that this is not a future theoretical problem: this is happening right now with wide reaching effects…..

Graham Martin et al in the BMJ editorial: A decade after Francis: is the NHS safer and more open? BMJ 2023;380:p513 Recurrent organisational catastrophes remain a disheartening reality .
It is 10 years since Robert Francis published the three volume report of the public inquiry into failings at Mid Staffordshire NHS Foundation Trust……

Helen Salisbury: Helen Salisbury: The new GP contract doesn’t deliver BMJ 2023;380:p590

“We are drowning, and you throw bricks at us.” This was just one of the despairing responses to the latest general practice contract, published in outline by NHS England on 6 March.12

With a growing population and record numbers waiting for hospital treatment, demand for GP appointments has increased markedly, while the number of qualified GPs has fallen. The new contract information acknowledges that 11% more appointments were delivered in January 2023 than in January 2020, but it fails to mention that this was done with 842 fewer full time equivalent qualified GPs.3

Practices are struggling not only with falling numbers of doctors but also with rising costs and wage bills. Those negotiating on our behalf have asked for help in the form of reduced box ticking and bureaucracy, financial support for energy bills, and help in retaining doctors.4 The new contract doesn’t deliver on any of these counts.

I looked up various definitions of “contract,” and in the hands of NHS England the meaning seems to have shifted from “an agreement” to “an imposed set of instructions.” One of the essential elements of a legally binding contract appears to have gone missing: that of “acceptance of an offer.”5 Perhaps somewhere in the past we all signed some forgotten statement along the lines of: “NHS England is free to adjust the contract in any way it likes and we will meekly submit, however ridiculous the ask.”

The stated aim of this new contract is to improve access to primary care. Yet it’s hard to work out from the information circulated so far what exactly we’re expected to do, how this will be measured, and what kind of sanctions (presumably financial) will be imposed when we fail. It says that “patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice.” But what does this mean? That every time a receptionist answers the phone they must do a full triage of the clinical problem? If so, we’ll need a greatly increased number of highly trained reception staff. Some GPs are already suggesting that we will inevitably, collectively, be in breach of contract, as it won’t be possible to deliver what’s being demanded of us. Perhaps it was never intended to be workable and is just more political messaging from the government, another populist stick with which to beat GPs.

If the intention really is to improve patient access, the effect is sadly likely to be the opposite. Encountering bricks when we asked for a lifebelt will be the final straw for many GPs, leading to yet more early retirements and diverted careers. For those with enough energy left for the struggle, industrial action becomes more likely. This decision is difficult for all doctors but particularly complicated for GP partners. Aside from our self-employed status, we feel a personal obligation to the patients we know and care for.6 We could just stop our non-clinical work—but if all we refuse to do is tick the boxes, engage with the Care Quality Commission, and attend our appraisals, will anyone notice?

The workforce plan that could be meaningless may arrive shortly. Political collusion and denial means many more deaths while the “honest debate” awaits..

The workforce plan that could be meaningless may arrive shortly. Political collusion and denial means many more deaths while the “honest debate” awaits..

The pressure is rising. The workforce plan that could be meaningless may arrive shortly. Many more deaths while the “honest debate” awaits.. A workforce plan for England only? Devolution has eroded fairness and has led to a stronger political collusion of denial..
On 10th March the NHS Confederation wrote a (closed?) letter to the Chancellor on the NHS Workforce Plan

Gemma Mitchell on 18th November 2022 in the Nursing Times: Hunt: NHS will get ‘independently verified’ workforce plan

The Independent reports: Thousands more medical degrees…and on 15th March 2023: Health bodies ‘disappointed’ Budget ‘did not acknowledge NHS workforce crisis’ – The Royal College of Nursing accused the Chancellor of ‘not yet gripping’ the issue.

The FT predicts the bill: Hunt’s workforce plan to cost £70,000 per person entering UK employment

The Guardian (Dennis Campbell 26th March) reports: NHS staff shortages in England could exceed 570,000 by 2036, leaked document warns – Exclusive: workplace plan sent to ministers says deficit will rise rapidly from current 154,000 if current trends continue … The NHS in England needs a massive injection of homegrown doctors. He asks “Will Jeremy Hunt foot the bill for NHS staffing? The signs aren’t promising…”

Lucinda Allen in the BMJ opines 24th March 2023: Adult social care urgently needs its own workforce plan

The Nuffield Trust and the Kings Fund report on the Public satisfaction with the NHS and social care in 2022: Results from the British Social Attitudes survey ….  Public satisfaction with the health service has slumped to its lowest level ever recorded in the 40-year history of the British Social Attitudes survey.

And in BMJ letters Fiona Myint eruditely explains the “big issue”. A “Workforce plan is meaningless without numbers”.

The reality is that for most of us the state safety net is absent. If social care is means tested, then why not health care?

44,000 Nurse vacancies = 12% of the workforce. Cheaper staff and less spend means more deaths…

More deaths in Wales. More attempts at unreal solutions… Across the nation standards are falling…

BBC News March 2023: Mum’s four-year struggle to find NHS dentist for sons

BBC News: Southend Hospital nurse quits over Twitter due to pressures

A NHS nurse who said he could no longer face going into work live-tweeted his resignation. Matt Osborne, a nurse in Southend-on-Sea in Essex, said he had seen an “exodus of staff. I have seen colleagues commit suicide. I am done, and I am handing in my notice today”. He has been a nurse for 19 years and has worked in emergency care for 14. The trust for Southend University Hospital, where he works, said it had seen an increased number of nurses. The Royal College of Nursing said it was “awful that people are leaving” and “we really need to see change”. Mr Osborne’s tweet,…..

BBC news 29th March: The future of the NHS – what do the experts think? includes differing medical opinions. Those interviewed are NOT the experts: it is public health and politicians together who are the experts. Yes, the public has to have a say, and they will always ask for services to be free, while death rates increase and life expectancy, especially for the poorest, decreases. The important thing is fairness, followed by encouraging autonomy, and discouraging dependency on a paternal state. Once that is accepted we can follow Enoch Powell’s maxim: The essence of a good rationing system is that which is unacknowledged; for it is the essence of a good rationing system to be intelligible and consciously accepted. (Medicine and politics 1966)  

Being mentally ill in todays unrationed but prioritised health service, means that voters and elderly will get more resources than young mentally ill non voters..

Who has the courage to fix our failing NHS? Health and Social Care reform will probably have to wait until things get even worse. I do hope I am wrong..

Worsening health ahead for the UK – A population in denial.. And it’s going to get worse still..

All 4 services are inefficient. Devolution has made this worse. Full throttle fridays would be a start..

Strikes. Medical student and new doctors’ finances. A nightmare for the chancellor and an additional threat to sustainability.. The strikes are a symptom of unhappiness…

The cost of becoming a doctor is becoming so high that only the “Medical Caste” are prepared to go through it. Nevertheless its noting like as bad as the USA, or India. The threat of strikes by teachers and doctors (Top medic says a bad effect on waiting lists, but this is denied in the letters! ) is higher than it might be because they are more valued abroad.
Scott Nelson for MoneyNerd reports 23rd Jan 2023′: Average Medical Student Debt UK
…In the UK, medical students will rack up between £50,000 and £90,000 of debt. This will vary depending on how long they were a student and where they studied. 

• In 1997, the average student debt from medical school was only £6,758.
• In 2013, before annual tuition fees increased from £3,290 to £9,250, the average debt of a medical student in the UK was £16,167.
• In 2019, the average debt for a medical student rose to £43,700.
• The average medical student is unlikely to ever repay their student loan….

The Guardian reports: ‘Exhausted’ medical students in England struggle to qualify amid financial woes

The BMJ reports: The lifetime cost to English students of borrowing to invest in a medical degree: a gender comparison…. Medical graduates on an average salary are unlikely to repay their SLC debt in full. This is a consequence of higher university fees and as SLC debt is written off 30 years after graduation. This results in the average female graduate repaying more when debt is low, but a lower amount when debt is high compared to male graduates.

Despite their initial altruism (all medical students appointed), as doctors some 6-8 years later they are sadly disillusioned. The reasons are complex, and NHSreality has been warning the implosion would happen since 2013 if we did not change the system.
The Times leader 15th March opines: The Times view on doctors’ strikes: Do No Harm – Doctors are risking patients’ welfare in pursuit of an unrealistic pay claim but the reality is evident in their working conditions, lack of support, bullying, gagging, declining standards (especially in half closed peripheral District General Hospitals) and lack of “exit interviews” to give reliable feedback.

Metro: I’m a medical student struggling with the rising cost of living

BBC News: Final year medical students ‘can’t afford to pay rent’

The Times: University bosses call for money to help fix NHS staffing shortages

Studying Medicine: A Guide To Medical Student Finance | BMJ Careers

Trainee doctors leaving university with over £100,000 in debt amid cost of living crisis – Mirror Online

Medical School Debt (The No-Nonsense Guide)

Average Medical School Debt [2023]: Student Loan Statistics (USA!!)

June 2022: Scottish Daily Express: Top doctor blasts SNP for crisis in ‘mismanagement’ in Scottish NHS and Retiring GP blasts the lack of leadership (Aberdeen Journal March 13th 2023)

BMJ 11th March: Consultants in England are “ready to strike,” as 86% vote in favour of action & GPs to consider industrial action after NHS England imposes contract

• Comments on the strikes: Poor management planning and sad, disillusioned juniors
• The doctors union was ripe for the plucking.. Doctors should never (have to) strike..
• Looking forward to a meaningful and mutually agreed long term manpower policy… – some chance
• A workforce plan without numbers and time lines – will be meaningless. The plan needs to cherish to retain!
• An increasingly “caste” system in medicine. Increasingly doctors train abroad & privately: litigation correlates.. Sad that no politician will take reponsibility or tell us the truth and plan long term.
• BMJ: Pay satisfaction among junior doctors plummeted in 2022, shows staff survey

The Daily Echo: ‘Real concerns’ over investigation into patient safety and bullying culture at NHS Trust – The Parliamentary Health Service Ombudsman said it had received more complaints about the trust in the past three years than any other.

ITV: NHS hospitals at risk of ‘sudden collapse’ put patients in danger, new report says

NHS patients in Wales are twice as likely to be stuck on waiting lists

The Sun: NHS PATIENTS in Wales are nearly twice as likely to be stuck on an NHS wait … highest patient satisfaction in history when there was a Labour government in Westminster.

Times letters 16th March 2023: Rights and wrongs of junior doctors’ strike

Sir, Comforting though it may be to believe that unrest is due to agitation by a small group of activists, such a belief is self-deluding (“Doctors must fight this militant takeover”, Mar 14). Anger, frustration and demoralisation are felt by the overwhelming majority of doctors of all grades, along with other healthcare staff who have experienced more than a decade of pay erosion as well as inadequate resourcing of UK health and social care. Melanie Phillips argues that junior doctors should be content with the nebulous concept of “feeling valued” rather than expecting a better rate of pay. Sadly, a lovely warm feeling does not settle student debt, the rent, mortgage or childcare fees: small wonder that our juniors are leaving to work in countries that are prepared to reward their hard work appropriately.

I am sure there are consultants who disapprove of junior doctors striking, but discussing it with my consultant colleagues I have not yet found one: the vast majority of us support our junior colleagues’ fight for pay restoration. Phillips believes that doctors should not be permitted to strike. If we had a truly independent pay review body, run according to the principles on which it was originally founded, and if we had a government that did not cynically abuse its position as monopoly employer, we would not need to.
Dr Cath Livingstone
Consultant anaesthetist, Galashiels

Sir, Melanie Phillips is right to say: “Quite simply, doctors should never strike.” That is not to deny that working conditions in the NHS are now abysmal. Pay has been eroded and staff shortages have added to the already enormous pressures of trying to make a creaking system function. Most demoralising for doctors is the knowledge that they can no longer practise the timely and high-quality medicine that their long training instilled. But there are ways other than withdrawal of labour to achieve such obviously needed reforms, the ballot box being the ultimate choice in a democratic society. Inflicting greater hardships on, and indeed risking the lives of, the patients entrusted to their care is not a morally acceptable way for doctors to make their case.
Dr Michael J Hall
Consultant physician (ret’d), Hereford

Sir, I was saddened by Melanie Phillips’s piece. It is not long since she, like most of us, was presumably expressing gratitude and admiration for doctors who kept the NHS running during the pandemic at great personal risk. Now she lobs the lazy “do no harm” challenge at people who were miserably treated by the present chancellor when he was health secretary (they “accepted” the new contract under duress, hence the stored resentment now leading to greater militancy).
John Bagshaw
Mortimer, Berks

Sir, Junior doctors are not putting their case well to the public. I have just reviewed the tax return for a junior doctor who graduated in 2016 and works full-time for the NHS; she earned £50,307 from the NHS in the year to April 5, 2022, before tax and significant professional fees. This is not exciting remuneration six years after graduating. What is more significant, however, is her unremunerated hours in that year. The culture of unremunerated hours expected from junior doctors would not be tolerated in any other profession. In her case, these hours exceed her annual leave.
Giles Craven
Chartered accountant, London SE21

Update – Times letters 27th March 2023: LOST FAITH IN THE BMA
Sir, Professor Mark Saunders suggests that the leaders of the British Medical Association are donkeys sending frontline doctors over the top to promote their extreme political agenda (letter, Mar 25). Only about half of British doctors are BMA members. The other half choose not to be associated with a trade union reminiscent of Arthur Scargill’s NUM. Historically the BMA has sole rights for negotiating terms and conditions of service with the government. All doctors should be consulted as to whether the BMA should continue to represent them in such negotiations. I predict that a majority would reject this. What body should take over this role? All doctors are registered with the General Medical Council as a condition of practising medicine and the GMC has responsibility for holding doctors to account for their actions. A new division of the GMC could be tasked with the cool negotiation of terms and conditions. The GMC would be unlikely to condone strikes but at least medicine could reclaim its professional destiny.
Dr Adrian Crisp
Ret’d consultant physician, Weston Colville, Cambs

Sir, At best the latest junior doctor strikes (report, Mar 24) can be viewed as an angry gesture from a frustrated, ill informed and badly led workforce. At worst it is an act of health terrorism, holding the health and lives of the people of the UK to ransom. I fail to see how anyone could view them as a genuine effort to advance the negotiations. It should be simply unacceptable for a doctor who is committed to the health of his or her patients and the survival of the NHS to consider strike action that is so clearly designed to cause maximum harm. I fear that the leadership of the BMA junior doctors committee is changing the nature of what it means to be a doctor in the UK, and not for the better.
Dr Brian Shields
Consultant paediatrician, Coventry

Times letters 28th March 2023: Junior doctors’ strike and faith in the BMA

Sir, We were dismayed that your leading article and subsequent correspondence adopted such a critical view of the junior doctors; apparently their strike action is ignoble and risks tainting the whole profession (“Wrong Medicine”, Mar 25). All across the nation junior doctors, many with young families, went in to work every day during the pandemic, putting their lives at risk to treat patients infected with a highly transmissible and dangerous virus. Their political persuasion or membership of the BMA (letters, Mar 27) did not matter then and it should not matter now. Notably, these young men and women worked with frequently inadequate PPE at the same that the prime minister, Boris Johnson, was insulting the country’s intelligence with his alcohol-fuelled “work events”.

Putting oneself at risk for others, as those young doctors did, would be a good use of the term “noble” and beyond what many older doctors faced in their careers. Forty per cent of junior doctors are planning to leave the NHS as soon as they can find another job, according to the British Medical Journal, or to move abroad for more sympathetic terms and conditions, chronic and substantial pay erosion being a major factor.
Dr Mary Cole and Dr Richard Cole
Salisbury

Sir, Dr Adrian Crisp suggests the GMC could replace the BMA in the role of pay negotiation for doctors. As a retired GP I have some experience of both organisations, having chaired the local medical committee of the BMA for 14 years and having been involved in the GMC investigative and assessment processes later in my career. While I completely agree that the present BMA leadership is clearly unfit for purpose, the way forward is not to blur the role of the professional regulatory body (the GMC). It is essential that regulation stands independent from representation and pay negotiation. The solution is for the profession to elect representatives at national level representing their views at ground roots level and vote out the hard left individuals who at present appear to hold power.
Dr Paul Wilson
Ret’d GP, Doncaster

Sir, Further to Dr Crisp’s letter, the GMC does a good job representing the interests of patients, but in my experience and the experience of colleagues over the 48 years of my career, is that the GMC did not represent doctors’ interests at all. To hope that a new division would alter this attitude is, in my opinion, extremely unlikely.
Dr Hercules Robinson
Ret’d GP, Ullapool, Ross & Cromarty

Sir, You report that the government wants to make appointments easier for patients to book (“Call to end the 8am scramble for a GP”, Mar 25). Before that, though, the government should stop issuing misleading information about the number of GPs: it quotes GP numbers, not full-time equivalents. More than half of GPs work part-time. Moreover, as the population ages the amount of time a patient requires per appointment rises: ten minutes is not enough, and 15 minutes would allow only 48 patients to be seen per day if the GP worked for 12 hours. The BMA and the European Union of General Practitioners recommends a maximum of 25 patients per GP per day. The only way to increase the number of patients seen per practice per day is to hire locums, as there has not been an increase in GP full-time equivalents over the past five years. Hence it is the government that needs to do its job before practices can increase the number of patients seen per day.
Dr Martin Seely
GP (ret’d), Worsley, Manchester

letters 29th march: BENEFIT OF THE BMA
Sir, Dr Adrian Crisp (letters, Mar 27 & 28) says that only about half of British doctors are BMA members. The true figure is nearer two thirds. Further, to say that “the other half choose not to be associated with a trade union” is incorrect. My recollection of industrial relations during my career in the NHS is as follows. There were always doctors who did not like to make waves over poor working conditions and unreasonable pay, but whenever the BMA organised a proper reaction to such injustice and obtained results in the form of improved terms and conditions, none of these pusillanimous doctors ever turned down the enhancements thus achieved. In fact, most of them pulled themselves up to the table and helped themselves handsomely. The real issue is that neither the government nor the Department of Health has consented to engage with any meaningful negotiations with junior doctors for the past 15 years, and the junior doctors are desperate.
Dr Jocelyn Wace
Retired consultant anaesthetist; Southsea, Hants

Update 12th April 2023:

Times letters 12th April 2023:

Sir, Your leading article is spot on but its balanced tone is kinder than the BMA deserves. There is more than a “suspicion” that the union is driven by political animus. For at least 30 years the BMA has been undermining doctors’ morale for its own purposes. In 1995, in a satirical BMJ article entitled “The British Misery Association”, I wrote: “The BMA has steadily hammered home the message that being a junior is as much fun as cleaning toilets in Sarajevo. So I suppose we must take credit for the fact that young doctors now see their first duty as making war on managers.” The BMA’s methods are no longer a joke. They are doing serious disservice to junior doctors.
James Owen Drife, emeritus professor of obstetrics and gynaecology

Sir, Steve Barclay continues to say that the BMA is a militant union and that the junior doctors’ demands are unreasonable and unrealistic, a sentiment echoed in your leading article (“Doctors’ Disorder”, Apr 11). The 35 per cent pay demand is not wholly unreasonable — MPs’ salaries increased by 31.7 per cent between 2010-11 and 2021-22. MPs achieved that increase incrementally over the 11 years, an option denied to junior doctors — hence the need to catch up. Thirty-five per cent need not be achieved in one go. A perfectly reasonable position for the government would be restoration over, say, a five-year period, maybe with a sweetener this year.

I fear that failing to restore pay to an acceptable level will mean that the NHS workforce remains stressed and overworked, leading to a continuing haemorrhaging of doctors leaving to work overseas or outside of medicine. Someone very senior in government needs to grip this situation and get down to some serious negotiating, rather than negative briefing which inflames matters and may be prompting some moderate doctors to become militant.
Chris Metz
Winchester

Sir, Melanie Phillips could, with equal justification, have started her article “This week the government is continuing putting the health and lives of sick people at risk by continuing to underfund the health service” (“Militant unions thrive in a weaker society”, Apr 11).

She writes that “there is an explicit aim to bring down the whole political order”, and cites Frances O’Grady’s view that the Conservatives are toxic and it’s time for a change. Getting rid of the Tories would not be bringing down the whole political order, it would be the electorate exercising its right at the ballot box.
Will David
Knockholt, Kent

The real reasons for implosion: The “morale-sapping impossibility of delivering high-quality care within a failing NHS.” Times letter 12th April 2023.

Sir, A doctor interviewed on Times Radio (Apr 11) said that although the “ostensible” reason for the junior doctors’ strike was pay, the underlying reason was the dysfunctional state of the health service, and the discontent with working conditions. It is a missed opportunity that the BMA stresses the need for “full pay restoration” and makes no mention of an issue that is equally (if not more) important for doctors: the morale-sapping impossibility of delivering high-quality care within a failing NHS. The BMA (and the junior doctors they represent) need to agitate for a full, open, cross-party review of the NHS with the aim of restoring high standards of patient care and safety, and regaining the professional satisfaction that should be part and parcel of being a doctor.
Tony Evans
Harrogate, N Yorks

Update 13th April 2023:

The Times letters 13th April 2023: Doctors’ strike and the BMA pay demands

Sir, In my emergency department in Sydney, more than two thirds of the resident, registrar and consultant doctors were trained in the NHS. If the British government will not pay its doctors properly, we will.
Dr Joseph Marwood, Staff specialist (consultant) in emergency medicine, Northern Beaches Hospital, Sydney

Sir, I sympathise with the predicament of junior doctors (my own daughter is one such) given the steady erosion of their real pay over the past decade, but an immediate claim of 35 per cent is unrealistic and will not sit well with the rest of the population, who are also struggling. That issue ought to be addressed in the fullness of time, but meanwhile a useful part of the negotiations should be an immediate mitigation of the high burden of student debt that these young people are forced to carry for decades.
Henry Wyatt, Harrow Weald, Middx

Sir, It is clear that junior doctors are thoroughly disenchanted with their working environments. This strike is not just about pay but a deeper dissatisfaction and disillusionment with working environment and roles in teams. Striking junior doctors should place less emphasis on unrealistic pay demands and more on improving these things, which would require concerted action by doctors of all seniorities.
Andrew Millar, MRCP, Wallingford, Oxon

Sir, Your leading article (“Doctors’ Disorder”, Apr 11) is off the mark in blaming the BMA for the junior doctors’ industrial dispute. If the BMA’s claim that junior doctors’ pay has been eroded over many years in real terms by 35 per cent is accurate, surely the onus is on the government to say how it proposes to deal with this and the resulting shortage of staff. Only once that has been done is it appropriate to blame the BMA for the impasse.
Henry Warren, Down Thomas, Devon

Sir, I am ashamed by the four-day strike. As a former GP I resigned from the BMA in the 1970s when strike action was called for, and as a junior doctor at that time I was earning 50p an hour as we worked many more hours than they do today and with no overtime. The BMA has been taken over by a majority of hardline left-leaning activists.
Dr Chris Westwood, Yealmpton, Devon

Sir, It seems, at the very least, a conflict of interest for Robert Laurenson to go on holiday in the very week that he has orchestrated the junior doctors’ strike (report, Apr 12). It raises the questions of how seriously he takes the pay issues of his colleagues, and how seriously he takes the plight of patients affected by the strike. Dr Laurenson appears to be in the relatively happy position of being able to make choices and will be considered by many, on this occasion, to have made the wrong one.
Lucy Hall, Tunbridge Wells, Kent

Sir, One of the most depressing aspects of this strike is the sight of intelligent, well-educated people standing with placards and chanting moronic slogans. This is the type of behaviour one associates with some of the people who cause disruption at football matches, and not what we expect from medical professionals.
David Kidd, Petersfield, Hants

The Times letters 14th April: DOCTORS’ DISMAY
Sir, Striking doctors (letters, Apr 12 & 13) will be back working in the NHS on Saturday. More worrying are those who will not because they have left medicine altogether. Understanding why highly motivated young people walk away from the profession is fundamental to a long-term solution. It’s not all about the money.
Sir Peter Rubin
Emeritus professor of medicine, University of Nottingham

The doctors union was ripe for the plucking.. Doctors should never (have to) strike..

The great thing about the 4 health services as far as our politicians are concerned, is that they have deferred day to day budgetary responsibility and development to non-political persons. These willing managerial scapegoats know that they must move on before the changes they have initiated are shown to fail. The German or the Dutch models are far better mainly because they are not politicised.
The BMJ is the best medical journal in the UK and is world renowned. To obtain it costs membership of the BMA union and after joining their support is assumed. The cost of the BMJ without membership is much higher. The only other way to get it is at your local postgraduate library, or by “sharing” a password access (illegally?). Most coal face workers are too busy to attend conferences and meetings, and junior doctors throughout the country fail to take much interest in the “unionised” activity of the BMA. So annual meetings of retired or semi retired “old farts” do not represent the juniors, but neither does the left wing who have found the time to attend, and take over a union that was ripe for plucking. Riddled with debt, overworked and trying to balance a normal existence with a family life seems impossible, (as the TV series Maternal shows only too well) the young doctors do not feel cherished. In these circumstances just a few can shame a majority onto supporting them, which is what has happened. The list of posts from NHSreality since 2014 (below) reflects the inertia of politicians and the combination of this and an ill union has led to the strikes.
Melanie |Phillips in the Times 14th March 2023: Doctors must fight this militant takeover – Instead of striking, medics should turn anger on the far left, which has infiltrated their union

The unprecedented three-day strike now under way by England’s 61,000 junior doctors is a shocker. The doctors are providing no emergency cover and making no exemptions for maternity care or cancer treatment. Thousands of operations and medical procedures are being cancelled.
The British Medical Association has told its members they don’t need to inform their trusts that they’ll be striking. It has also told consultants not to cancel any private work to cover NHS rota gaps. In other words, the BMA has set out to cause as much life-threatening chaos as possible and make it more likely that sick patients will be harmed. How can doctors of all people behave like this? Professor Philip Banfield, the BMA’s chairman of council, claimed on Today that because consultants would be providing care the NHS would be “even safer than normal”. What astonishing cynicism. The BMA has recommended that consultants should charge astronomical rates of almost £270 per hour to cover juniors’ shifts. And even with any such cover, there will still be disruption, delays and cancellations.
Nurses and ambulance drivers have put their own threatened strike action on hold while negotiations take place with employers and the government. The junior doctors were offered the same arrangement but turned it down. A bill currently in the Lords aims to allow the government to require minimum service levels to be maintained during strikes in essential services, including the NHS. Junior doctors should be meeting this requirement anyway. Their grievance is over remuneration. Yet they pretend it’s all about saving the NHS. This is humbug.
In 2019, the junior doctors accepted a new contract which gave them an 8.2 per cent pay rise over four years. Dr Jeeves Wijesuriya, chairman of the BMA’s junior doctors committee, said: “We have made major strides towards a better future for all junior doctors.” Yet the doctors say they now want a rise of about 35 per cent to reverse a real-terms pay cut since 2009 of 26 per cent. The BMA claims the situation since 2019 has changed as a result of the pandemic, cost of living crisis and rising inflation. ~Yet in online chats with other medics Banfield’s deputy, Emma Runswick, reportedly admitted that “quite a lot of juniors” were still quite comfortably off, and they would be able to work part-time if strikes led to a large pay rise.
The junior doctors claim they are “undervalued”. This is absurd. The public value them hugely. If they think the NHS doesn’t value them, that’s because it’s on its uppers and has become an administrative basket case. Waiting lists for elective care are vast, post-Covid pressures are massive and there’s a huge number of unfilled vacancies across all parts of the system. Doubtless many doctors are leaving the NHS. The reason, however, is the toll being taken on them by a system that the doctors, like the government, refuse to admit is broken beyond repair and needs to be rethought from scratch.
We can all sympathise with the exhaustion and demoralisation that come from working all hours in a failing institution. The junior doctors are also coping with graduate debt and a painfully high cost of living. But these are privations experienced by many others. Whatever the pressures, how can they claim to be trying to save the NHS when their action threatens the welfare of sick patients and may even kill some of them? Whatever happened to the ancient Hippocratic oath that tells doctors “first do no harm”?
Quite simply, doctors should never strike. Many senior doctors are horrified by the juniors’ action and say they don’t recognise the profession they joined. That’s because the BMA is no longer just a doctors’ trade union but has become signed up to the united “workers’ struggle”. Last summer, it put out a statement expressing its “solidarity with rail workers and the RMT in their ongoing dispute”, and donated £1,000 to the RMT strike fund. This represented, said the BMA’s Banfield, “the essential bond shared between organised workers today”.
The BMA’s tactics come straight from the hard-left playbook. Internal BMA documents instructed activists to draw up secret files on their colleagues’ attitudes, saying they should “build up knowledge of every junior doctor who works at your NHS Trust”. They also said each colleague should be assigned a numerical score to track their loyalty to the union’s push for higher pay.
The ringleader of this militancy is Runswick, a 27 year-old, self-described “unashamed socialist” who was voted deputy chairman of the BMA council last July. Another junior doctor elected to the council was Rebecca Acres, 31, who described the Labour party under Sir Keir Starmer as “proto-fascist red Tories”. These militant junior doctors took over the BMA through classic hard-left entryist tactics. A small number, mainly in their twenties and early thirties, formed the Broad Left group and plotted on the website Reddit to nominate candidates for the union’s council. Co-operating with another left-wing group, Doctors’ Broadsheet, they secured 26 of 69 council places last spring.
These activists bragged online about achieving “multiple changes at multiple levels of the BMA” and being “politically very astute” by “inserting candidates sympathetic” to their agenda in positions of power. That’s why, rather than “do no harm” to their patients, they have decided to do harm and then blame the Tory government. And the silent majority in the medical profession, whether clueless, supine or just tactically outclassed, have let it happen.

2017: Reflections on the BMA conference in Bournemouth. A complete lack of trust.. & Top GP warns of threat to NHS as BMA calls emergency conference

2019: We have to make charges, and overseas patients are just the beginning.. The BMA motion shows just how non-representative they are. & BMA Chairman tells it as it is. Even he still refers to an “N”HS… and he has ignored the need to ration.

2018: “Serious risk of collapse”. The BMA represents the majority of consultants and GPs thoughts, and not the Royal College of GPs (RCGP). We ALL need to worry. Its going to get worse, until we face up to reality.

2016: Unhappiness all over the 4 Health Services. Party conference collusion in denial.. Resignation letters from GPs?

2015: Unprecedented – BMA crisis meeting called Mr Hunt unites the profession: BMA membership surges amid dispute over contracts

Looking forward to a meaningful and mutually agreed long term manpower policy… – some chance

NHSreality looks forward to a meaningful and mutually agreed long term manpower policy… But the politicisation of health in the UK makes this most unlikely. The seamless transition from health to social care is only possible if there are changes in philosophy. Either the social care becomes free, as the health service, or health has co-payments as for social care. There is no possibility of the latter for Labour or the Liberals, and there is no chance of the former for the Conservatives – meaning no cross party agreement – some chance for the manpower review being acceptable and workable! Add to the Ministers’ problem of the seduction of newly trained doctors overseas, and that Wales and Scotland give students more money, and readers will recognise the perverse and regressive nature of training more doctors in poorer Regions.. All NHSreality can offer is to “go for an excess”, and allow for the overseas overflow! Better housing, mentoring, work environment, and pay will help..

Letter in the Times 14th March 2023: STAFFING THE NHS
Sir, Caroline Abrahams (letter, Mar 13) pinpoints a problem inherent in a highly politicised health system: politicians may be reluctant to put figures to policy commitments because of fears that targets, in this case the number of medical staff needed to operate a fully functioning NHS, are not met. A realistic long-term workforce strategy, commensurately funded and not subject to political winds of change, is overdue. Such a strategy needs to recognise the interdependence of health and social care and the implications for training more doctors, nurses and other staff. Recent columns in The Times have suggested a number of sensible ways in which NHS workers could be made to feel more valued and respected, including better childcare arrangements, free staff car parking at hospital sites, heavily subsidised catering, and better rest facilities and amenities to promote fitness and wellbeing, as well as a sensible pay settlement. The Messenger report published last year emphasised the urgent need for a more supportive and collaborative management culture to help to make the NHS a better organisation in which to work.
Professor Roger Jones
Emeritus professor of general practice, KCL; London SE1

The non pharmaceutical options – GPs are reluctantly resorting to medications for patients desperate for an answer now. To change we need politicians with balls..

Some 3 years ago the French announced, through Mr Macron, that they would be reinvesting monies saved by not prescribing for certain conditions and circumstances (Rationing) but would re-invest the money into therapists. The payback period might be 10 years or more and if there is a new president and a new politics all his good work could be undone. The idea that a drug answers immediate need is of course false. The anti-depressants really don’t work well. We have been conned for long enough. The answer is not both drugs and therapies but replacement of the one by the other …. This needs a bold political decision!!

Times letter 4th March 2023: KEEP TAKING THE PILLS
Sir, As a GP who works with people with chronic pain, I would much rather avoid prescribing costly antidepressants and opioids, which require regular prescriptions and review, and frequently result in multiple side effects with often only small benefit (“NHS plan to help millions stop using antidepressants”, Mar 2). However, these patients suffer both physically and mentally, and are desperate for a solution. The present wait for cognitive behavioural therapy is several months, even more for those with complex trauma, as many chronic pain patients have. Very few areas have access to alternative therapies such as art or music. What am I meant to offer them? It is no wonder that GPs are reluctantly resorting to medications for patients desperate for an answer now. Until the NHS meaningfully funds non-pharmacological interventions and community mental health services there will be no other option for GPs.
Dr Selena Stellman
GP in northwest London; Thames Ditton, Surrey

Chronic pain relief and Psychiatric conditions all need therapists… They have been rationed out.

The Health Service(s) were conned by Big Pharma

Sensible rationing of dementia and depression drugs – a lead from France

Medical Training needs to be deeper – so making it shorter is high risk,

The economic and efficiency benefits of the GP service (as it was) are evident to all Ministers of Health. If it takes time to train a mature doctor he then has used time as his own diagnostic tool. Medical Training needs to be deeper (its a much larger curriculum every year) – so making it shorter is high risk. As NHSreality has pointed out before, the best use of “time” for medical education is to only appoint graduates. The GP generalist diagnostician is invaluable?: he prevents over investigation and wasting of resources. He could, if sourced and trained properly, once again see 90% of the conditions presenting to the 4 health services for 10% of the budget.

2nd March in the Times letters: MEDICAL TRAINING
Sir, Robert Slack (letter, Feb 28) makes the case for very reduced training for “trained specialist doctors”. However, these already exist in clinical nurse specialists. They are largely responsible for my high-quality contact as a patient after my excellent GP has assessed me on the basis of much broader knowledge.
While super-specialisation has become the norm, there remains a vital need for doctors who are familiar with all body systems, recognise their common pathologies and understand their treatments. Without these, early treatment of common serious conditions is overlooked. Super-specialisation, such as ear, nose and throat, is much needed but depends entirely on prompt and appropriate referral by generalists in the event that treatment is beyond the scope of the latter.
Andrew Millar, MRCP, FRCS
Wallingford, Oxon

Sir, Some retired surgeons are quick to reveal that everything they needed to know could be learnt in two years. Pity the GPs, who for less money and prestige need to know everything. After 30 years I was still diagnosing conditions, for the first time, which I had only read about in a footnote at medical school. Nothing gets to the specialists without being directed to the right person by a GP.
Dr Nicky Lee
Haslemere, Surrey

Sir, As an 18-year-old medical student I was told that the whole point of a course lasting six years was to keep me away from the public until I was mature enough to deal with patients.
Dr Anthony Barson
Altrincham, Cheshire

A 3 year training for doctors needs to be graduate entry only.. It will be very tough… and is a risky form of rationing.. is Lord Darzi joining the gamblers and chancers who rule us today?

Undergraduate women will always outperform men. COGPED and the BMA need to promote more graduate, and less undergraduate entry, and many more places.

A dereliction of political duty on vaping

It was so obvious to the profession, but the liberal approach of our politicians seems to avoid any confrontation with business. When vaping was first proposed the profession asked for more independent evidence that it was not addictive. It never came and now we know the truth. This is indeed a long term repeat of the smoking and cancer story… It exposes a dereliction of political duty on vaping…

The Times letters 2nd March 2023: PERILS OF VAPING
Sir, Sadly, the massive growth in e-cigarette use among adolescents comes as no surprise to those of us who warned that this would happen (“ ‘Harmless’ vapes are creating teenage addicts”, Mar 1). Unlike public health organisations worldwide, Public Health England (now the Office for Health Improvement and Disparities) has been promoting these products heavily, arguing that restricting the features that make them most attractive to young people, especially flavouring, would deter the adults they wanted to switch from cigarettes. Although no longer using the discredited “95 per cent safer than cigarettes” claim, it at least accepts that e-cigarettes are not risk-free but seem oblivious to the evidence linking their use to heart disease. We always knew that it would be a struggle to counter the efforts of the tobacco industry to get a new generation addicted to nicotine but, sadly, in England, those who should have been protecting these young people did not even try.
Professor Martin McKee
London School of Hygiene & Tropical Medicine

Sir, It is worrying to see how many teenagers are trying vapes, attracted by the clever marketing, bright packaging, tempting fruit flavours and ready availability. The same thing happened 30 years ago when youngsters had their first taste of alcohol with fruit-flavoured alcopops. Alice Thomson rightly points out that vapes are intended to be a tool to help adults to stop smoking. Hence, access to them needs to be regulated and the glamour removed.
Nicotine craving lasts only about two to three weeks. The hardest part of stopping smoking is the physical hand-to-mouth habit. Vaping does not address this, so one is left with another nicotine-based habit to break.
Ruth Walters
Derby