Where have all the Doctors gone?

In 1985 around 3000 doctors graduated from university in the UK, and at that time there was a small but significant number of unemployed doctors. In 2015 the equivalent figure is 7500, an increase of 2.5 times, while the population of the UK has only risen by a few percent. How therefore is it possible that for the last few years, advertised jobs in General Practice and some specialities such as Emergency Medicine and Paediatrics commonly receive no applications?

And how can understaffing be causing huge problems in hospitals and primary care in many, though not all, parts of the UK? 

There are many reasons of course, and it is worth examining them in detail. It is not just a question of UK graduates going off to work abroad. Although that drain is increasing, the large majority only stay away for a year or two.

It is important to clarify that some specialties, for example surgery, are very popular and highly competitive. So we have to look at the problem areas specifically.

Emergency medicine has some obvious downsides as a career as it is a 24/7 job, and it attracts very few of the female doctors who now make up 65% of medical graduates. Importantly, it has a low status in the hierarchy of medical specialties, below Elderly medicine, and only just above General Practice! Even more significantly, it has become a sort of medical dustbin which has to deal with the consequences of all of the failings of the rest of the system. If medical wards are full because the council haven't got care arrangements sorted out for frail elderly patients, or because the heart specialist wants to keep a patient in hospital to get them ahead of a waiting list for a stenting procedure, it is the emergency department that has all of its treatment bays occupied. It is now common for emergency department doctors to have to treat patients who are lying in ambulances parked outside their departments. link to the Daily Mirror

Junior doctors working in Emergency Medicine also complain of unsocial hours ie shifts finishing at 2am, and working the majority of weekends, with no flexibility in the rota and little chance of more than 2 consecutive days off during Christmas. In combination with not being allowed to take leave for courses, and not being able to choose their holiday dates, this is enough to put most young doctors off.  

I have little experience of hospital Paediatrics, but it is very strange that a field which used to one of the most popular should have plunged to the bottom of the list. This may be a consequence of the way that brave and outspoken figures such as Professors Roy Meadow and David Southall have been punished for their exposure of parental child abuse. See Paediatricians letter to the GMC

General Practice traditionally occupies half of all doctors, but this proportion has been declining fairly steadily in recent years, and the number of doctors joining GP training schemes has been below the intended level for a while. This has partly been due to restrictions in GP training budgets, which are needed to fund the jobs in General Practices, but also because of a considerable shortage of doctors wanting to be GPs, despite the fact that it is a much shorter career path (3 years v around 7 for most specialists). GPs are also generally paid better than specialists with no obligation to work outside normal hours.  It is particularly odd when one considers that the newer medical schools have specifically been created with a focus on General Practice with subjects such as consultation skills at the top of the curriculum.

Anecdotally, young doctors seem to be put off mainly by the sheer difficulty of the GP job.  By trying to deal with 18 patients in a morning at 10 minute intervals, often negotiating a plan of action to deal with multiple problems, while also remembering to tick the boxes that are needed for QOF, and maintain a good medical record with a list of important diagnoses. They are afraid that the time pressure will lead to them making mistakes, and they think that brain surgery is likely

 to be easier! The oft quoted saying is that GP is the easiest job to do badly, and the hardest job to do well.

But this is only part of the story. Other important causes for the GP shortage are that the work has increased rapidly because of the QOF and other initiatives that have loaded them with extra work. The number of GP consultations per patient per year has increased from around 4 in 1995 to nearly 6 now.See the NHS report on GP consultation rate

According to a recent report from the Primary Care Foundation  Making Time in General Practice  a large number of these consultations are unnecessary. In particular, their analysis suggests that 4.5% of GP consultations or around 17million GP appointments a year are due to Hospitals pushing work onto GPs that they should be doing themselves. The main categories of this are telling patients to get prescriptions and certificates from their GP that they should themselves be providing, and patients having to go to GP’s to sort out problems with delayed and cancelled hospital appointments and to get hospital test results.

This is odd because the number of hospital doctors has been rising rapidly in recent years. Between 2009 and 2014 the number of consultants rose by 4.1% annually – from 37,000 to nearly 44,000 according to NHS workforce statistics  Meanwhile the GP workforce in so called Whole time equivalent doctors, has actually fallen slightly in the same period according to the Royal College of GP's report  

The GP shortage has been exacerbated by a large increase in the number of Doctors taking early retirement. This has been a result of various policies introduced in recent years. QOF has reduced job satisfaction among GPs. Doctors in small practices have been pushed into joining up with larger practices which they rarely find congenial. Doctors have been forced to pay a lot of money into their pension scheme so have large so called pension pots. When it was announced recently that tax relief on payments into the scheme would be stopped for larger pension pots it made it much more attractive to start taking the pension early, while still working part time.  

Then these 55+year olds who were claiming their pensions were forced to take part in the system of professional " Revalidation" introduced by the government in the wake of the Harold Shipman affair.  Under these rules, continuing to be licensed to practice depends on a satisfactory yearly appraisal, with a minimum number of sessions worked, evidence of audit projects, evidence of a completed professional development plan, discussion of complaints and feedback, and evidence of compliance with GMC guidance. Liability insurance costs are rising by 20% or so per year and are now around £11,000 per year for a full time GP. see GP magazine. As a result of all this, a huge number of experienced GPs, who would otherwise have continued as part timers, are deciding that it is not worth the hassle, and are retiring completely. This wastes a very valuable resource as these doctors tend to be very cost effective in terms of prescribing and referrals, and tend to be more efficient in terms of patients needing less follow up visits.

This change was introduced at the same time as a new stricter exam taken by Junior doctors training to be GP's. In the first cohort the pass rate was only 65%, which meant that the supply of new GPs was at least for a time cut by nearly a third.

The result has been that in some areas there are now few UK graduate GPs. Doctors naturally tend to want to work with a team of colleagues who have had similar training and experience, which has exaggerated the differences.  The difference in the GP workforce between for example Cambridge and Scunthorpe is now enormous. The less popular areas are now struggling very badly to recruit GPs, who are likely to leave again if they get a better offer. Several practices have simply closed, although this means the partners sacking long term employees and thus being liable for large redundancy payments.

Practices are not allowed to employ doctors who have not successfully completed GP training even as temporary staff, although they are allowed to use nurses and pharmacists without any particular GP training, so there is no potential for hospital doctors to help out. Instead nurses, and pharmacists, are being employed to fill the gap. This is economical for the practice but tends to increase overall demand on the health service through increased referrals. Referring patients to specialists might be thought to reduce GP workload but in fact the opposite is true, as each outpatient visit usually leads to another consultation with a GP.

Overall, there should have been plenty of doctors in the NHS, but the authorities have turned what out to have been plenty into a famine. None of the authorities mentioned above have direct responsibility for this issue, but it does seem short sighted that none of them seems to have anticipated the entirely predictable damage caused by their policies on workforce supply, and hence on the NHS.

Unless perhaps they did?

---

 [1]