Five questions the Government must answer

Health secretary Jeremy Hunt has announced an expansion in medical school places. Increasing the supply of new doctors could help the NHS, but if the policy is botched, it risks medical unemployment, diluting teaching quality and unfair treatment to international doctors.

A few lines in a conference speech, a huge and potentially destabilising effect on the health service and many more questions than answers left in its wake.

Does that sound familiar?

At the Conservative Party conference last week health secretary Jeremy Hunt sounded upbeat about his plan to increase the number of students at English medical schools from 6,000 a year to 7,500 in September 2018.

Health Secretary Jeremy Hunt announced medical school places would be increased from 2018, creating 'more home-grown doctors'

Health Secretary Jeremy Hunt announced medical school places would be increased from 2018, creating 'more home-grown doctors'

‘The result will be more home-grown doctors and fewer rota gaps in a safer NHS, looking after you and your family for years to come.’

But we’ve been here before. As with the ‘plan’ to expand seven-day services, there are benefits in principle but far more questions than answers.

With seven-day services, we’re still waiting for those answers more than a year after we pressed for them – fundamental points about staffing and funding.

There are benefits in principle, but far more questions than answers

Until the Government clarifies how its new policy will impact on students and the existing medical workforce, it risks unleashing the opposite effect on the health service, and putting off talented applicants. It also threatens a future NHS where medical unemployment is widespread, but those who cannot find jobs have to repay thousands of pounds in training costs as well as their existing student debt.

We are putting these questions to the Department of Health. We will keep you posted on progress.

If you have any questions you’d like to add to ours, email news@bma.org.uk

How will the Government pay for it?

How will the increase in places be funded from the existing Department of Health budget?

So far, the only figure quoted has been £100m. But 1,500 places at £220,000 would cost £330m.

Where is the money coming from?

The size of the financial problems faced by the health service is matched only by the size of the denials from the Government. A year ago, the chancellor boasted of a ‘fully funded NHS’, yet the £10bn he promised, when cuts elsewhere in the Department of Health were factored in, was actually less than half that.

The Government needed to plug a £30bn black hole by 2020 even before it announced its plan to expanded seven-day services, but plans how to do that and achieve £22bn in efficiency savings have been sketchy at best.

This Government has form when it comes to announcing grand ambitions without considering how they will be funded

So it has form, to say the least, when it comes to announcing grand ambitions without considering too carefully how they will be funded. Even in its flagship policy, expanding seven-day services, the BMA has been pressing the Government for more than a year with basic questions on how it would be funded, and it has yet to receive an answer.

Press reports have put an estimated cost of £100m on the plan, which would be enough of a tall order given the financial pressures already faced by the Department of Health, and which they have passed on, making real-terms cuts in public health, for example.

But with a little simple maths – 1,500 places at the Government’s figure of £220,000 a go – that takes us not to £100m but to £330m for a cohort of students.

All this in an NHS which, according to the King’s Fund’s review of health service finances earlier this year, is ‘working at, or very close to its limits and patient care will suffer unless more resources are found’.

How will it impact on medical students and medical schools?

Will this policy apply to English medical students who study in the other three UK countries? And what about Scottish, Welsh and Northern Irish students who go to English medical schools?

Has the Government modelled the consequences of the policy in terms of its impact on English medical school admissions, given that medical schools in other parts of the UK will most likely not be subject to the four-year tie?

Will the Government ensure that medical schools maintain the current tutor-to-student ratios?

Can the Government guarantee that no medical student will have to travel an unreasonable distance to a clinical placement?

So, you’re a bright sixth-former living in England. Over the border in Scotland or Wales, there are half a dozen excellent medical schools where – most likely – you won’t have to pay back the cost of training if you subsequently leave the NHS after four years.

Expanding numbers without expanding resources is bad for educational standards

You probably want to work in the health service, perhaps for life, but given that every year there is a minority of newly qualified doctors who find it isn’t for them, do you want to risk the ‘lock-in’?

That – and debts of often £70,000 – might just put you off medicine altogether, or at the very least lead you to apply for an ever more contested place in a non-English university.

Or, you go to an English university, and find that the extra funding has not materialised and the much-vaunted extra 25 per cent of students are all competing for exactly the same number of books, or for the attention of exactly the same number of teaching staff. And clinical placements, which can already be over-crowded or many miles from a place of study, are now, well, 25 per cent harder to find.

Expanding numbers without expanding resources is bad for educational standards and grossly unfair to students and those who teach them.

How will it affect doctors?

What was the evidence base for choosing four years as the minimum period that doctors have to work in the NHS?

What happens to the doctors subject to a minimum four-year term who can’t find a job in the NHS? Will they still have to pay back the cost of training?

What would happen if a doctor was unable to continue practising in the NHS before the end of the four-year period, for example on health or fitness-to-practise grounds?

What would happen to a doctor that took time out to have children, pursue academia or to recover from sickness?

Will the Government ensure sufficient numbers of foundation and specialty training places for the extra medical school graduates who will be entering the NHS?

How will the Government seek to enforce its charge for the cost of training upon doctors who move abroad to practise medicine during the first four years following their qualification?

The NHS is, more or less, a monopoly employer, and so the Government has a responsibility to ensure that medical graduates have a job at the end of it. It’s a moral responsibility to the students who might be borrowing £100,000 to fund their studies, but also a fiscal responsibility to the country, given the resources that universities and the health service put into a medical education.

The foundation programme for 2016 was over-subscribed once again, and 235 graduates had to be placed on a reserve list for places. It has been touch and go with the foundation programme for years, and some graduates have faced an anxious wait – the NHS has appeared not to have the money to expand the number of places even slightly to accommodate extra demand.

The risk of a workforce crisis of unprecedented proportions

So now, 1,500 new graduates will enter foundation training. The medical student places will be expensive, but so too will the extra foundation places, and then the extra specialty training places that the doctors will need.

The alternative is a workforce crisis of unprecedented proportions, a huge amount of wasted talent.

And then, for all the new graduates of English medical schools, there is the sword of Damocles of the four-year ‘tie-in’, where they have to stay in the NHS or repay potentially £220,000 in training costs.

Here, there are so many questions. What about the graduates who can’t find jobs in the NHS, or are unable to continue working for other reasons?

These questions need answering not when these graduates are entering the workplace in seven or eight years’ time, but now, because otherwise it offers a false or incomplete prospectus to those applying for medicine.

The Government might think this policy solves its Australia problem. Certainly, junior doctors have been voting with their feet and travelling in considerable numbers to work abroad.

The Government might think this policy solves its Australia problem

In September last year 3,500 doctors across all grades applied for the necessary GMC documentation allowing them to apply for foreign jobs in just 10 days following the health secretary’s threat to impose a new contract.

But there are plenty of scenarios where this policy could actually increase the exodus to Australia, New Zealand and other countries where doctors seem to feel more valued. Some might stay for their foundation years, but not begin specialty training, instead carrying out other NHS work until they are free to leave.

The Government is currently accused of driving junior doctors away from Britain. It may also run the risk of permanently exiling them.

Will it really help the health service?

What are the Government’s plans for dealing with the shortage of doctors in the NHS now, and in the years before the new medical students have graduated?

Why is the Government placing a priority on forcing doctors to stay in the health service rather than making it a more attractive place to work?

What message does the Government think it is giving about the state of the health service that it has to compel doctors to work there?

The Government suggests the increase will save on the locum bill, but won’t the new doctors merely be plugging the gap left by the departure of overseas staff?

Jeremy Hunt said the policy would result in ‘fewer rota gaps’. The rota gaps are certainly there to be filled.

In February this year the Royal College of Physicians’ survey found that 40 per cent of advertised consultant physician vacancies could not be filled ‘due to a lack of trained applicants’. In some parts of the country this raises above 50 per cent. The same survey highlighted consultants’ concerns that rota gaps could ‘cause significant problems for patient safety’.

As we’ve seen, in increasing student places, Mr Hunt seems to be assuming there will be jobs for the new doctors and money to train them. But he is also at risk of overlooking why so many of the rota gaps exist in the first place, why major specialties are facing a recruitment crisis, and why thousands of doctors are considering moving abroad.

So many of the reasons for this poor morale lie in the way that Jeremy Hunt has run the health service

The profession is profoundly demoralised. The BMA’s cohort study published earlier this month found that 42 per cent of specialty trainees were reporting high or very high stress, up from 29 per cent in the previous survey.

So many of the reasons for this poor morale lie in the way that Mr Hunt has run the health service. Years of real-terms pay cuts, blaming the profession for being a ‘road block’ to seven-day services when the vast majority already work weekends, imposing a contract that was rejected by junior doctors in England.

Instead of tackling these sources of poor morale, doctors are effectively being compelled to stay in an under-funded and demoralised service.

A four-year contractual hold, but little else to attract doctors

You might not agree with everything that Ronald Reagan said, but he had a point in the 1980s when he said there was something fundamentally wrong with a country that had to build a wall to stop its people from leaving.

We mustn’t exaggerate. There are no watch towers. But the threat of repaying the cost of training – up to £220,000 is about as much coercion as a Government can possibly exert.

If Mr Hunt’s plan goes ahead, he may have a four-year contractual hold over the medical workforce. But he has done little else to attract them to the health service.

How is this fair for international doctors?

Will international students who train and qualify in the UK be exempt from the four-year rule?

Will international graduates of UK medical schools and doctors, who are already committed to studying and training in the UK, be allowed to continue through the NHS training system?

What contingency plans do you have for the possible exodus of overseas doctors who now feel less welcome in the UK?

The Government has said repeatedly that the diversity of NHS staff is one of its greatest strengths. So why is it seeking to reduce the diversity of nationalities?

It has been a deeply unsettling three months for many of the overseas doctors who work in the health service. For some members of the public, Brexit gave them an unaccountable green light for outpourings of racism.

But even for doctors who escaped that abuse, there was suddenly an uncertainty they could never have anticipated.

Anna Riemen, a German Dundee University graduate, specialty trainee in trauma and orthopaedics and currently completing a PhD in Aberdeen, told us: ‘Until now, I’d been planning to stay and continue working here, and that’s still my plan, but I don’t know if it will be possible. It’s definitely looking rather more wobbly.’

As if the immeasurable enrichment that overseas doctors had brought since the foundation of the NHS was just a phase we went through

For overseas doctors in England, there is not just the fall-out from Brexit, but the rather trite statement from Jeremy Hunt at the Conservative Party conference. Overseas doctors did a ‘fantastic job’ but ‘we should be training all the doctors we need’.

It was as if the immeasurable enrichment that overseas doctors had brought since the foundation of the NHS was being reduced to that of a stopgap, a phase we went through until the as yet phantom legions of new, British doctors could pick up the slack.

In a letter to Mr Hunt, BMA council chair Mark Porter, and medical students committee chairs Harrison Carter and Charlie Bell wrote:

‘Our international doctors bring great skill and expertise to the NHS, and without them our health service would not be able to cope.
‘Medicine thrives on the interchange of experience, knowledge and training and as such we do not support the government’s ambition for an NHS that is 100 per cent self-sufficient: closing our borders would be bad for medicine and bad for patient care.’

A shoddy way to treat doctors who have often worked in the most hard-to-recruit specialties or the most deprived parts of the country

There are practical questions too. Medical schools have always attracted students from around the world, with those from outside the EU paying much higher fees which are a valuable source of income in further education. If they face immigration restrictions on working in the NHS, do they get penalised for it?

If even a fraction of international doctors have to leave, or decide to leave, it will negate the 1,500 increase in medical students and leave the NHS in an even worse situation.

As Manchester medical student Emma Runswick put it on Twitter:

It’s a shoddy way to treat doctors who have often worked in the most hard-to-recruit specialties or the most deprived parts of the country.

Worse than that, it seems a policy indifferent to whether a culture that draws the best and brightest from around the world turns inwards, and stops learning from those outside its borders.

Or if you want things a bit more earthy, listen to this anaesthetist who tweeted:

We want to hear from you.

Tell us if you have any more questions you'd like to ask the Government about their plans for increasing medical school places.

Email: news@bma.org.uk

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Content editor: Neil Hallows
Digital producer: Sarah Quinlan
Production editor: Chris Patterson
Senior digital producer: Karen Lobban
Senior writer: Peter Blackburn
Images: Matthew Saywell, iStock