Prognosis for NHS looks grim if juniors leave

Published on Monday 18 May 2009 21:54

FOURTEEN years ago I fell asleep in the middle of The Merchant of Venice. This was no mean feat, as the seats at the open air Minnack theatre were carved out of rock.

However, I had just completed an 80-hour continuous shift as part of a 126-hour week as a junior doctor. At that time, the idea of a 48-hour week was a pipe dream, but later this year when the European Working Time Directive is implemented, the sight of doctors catching 40 winks wherever they can will be a distant memory.

The reduction in doctors' hours is accompanied by inevitable fears that hospitals are going to become understaffed. It therefore seems paradoxical that NHS Scotland has announced a cut in junior doctor training posts by nearly 400.

NHS Scotland will employ enough doctors to treat patients, but an increasing number of these doctors will not receive formal training. This will save money, as actively training doctors is an expensive business, but is NHS Scotland entering into a false economy?

All medical graduates enter into a two-year foundation training programme designed to equip junior doctors with skills to enter a speciality training programme.

The problems start after completion of the foundation years, when doctors apply for Specialty Training (ST) posts. The application process for these positions is centralised, it occurs en masse and there is no room to apply to individual hospitals when a position becomes available.

ST posts are supposed to provide relevant training for a particular speciality. For example, there are training programmes to produce consultant neurologists and some to produce anaesthetists. Therefore, after completion of the foundation years, the junior doctor is under pressure to decide which branch of medicine they are going to practice. There is less ability for the undecided to "suck it and see" with a six-month job. Doctors applying for ST posts may have had little experience in the specialities they apply for. This is one reason Caroline Hutchison, a foundation doctor from Tayside, is leaving to practice in Australia.

She says juniors are "fast tracked into roles that they have little experience in – a year or two of experience before applying for training posts would be useful".

Ms Hutchison is interested in becoming a neurologist, but wants to broaden her horizons before she enters an ST programme.

Dr Andrew Conway Morris, joint deputy chair of the British Medical Association's Junior Doctors Committee, says her experience is not unique: "I suspect that doctors will continue to go overseas to gain additional experience in other health services, and indeed believe that such experience is important."

Ms Hutchison's experience gained in Australia should help her apply for an ST post on her return, but as the cutbacks will create a bottleneck at entry into training posts, her success is not guaranteed.

Doctors that are unsuccessful in their application to these posts may consider a fixed-term job, but many of these do not offer training and, in effect, are dead-end positions that junior doctors shy away from.

Numerous medics who do not get a training position prefer to gain valuable experience abroad rather than work in a job perceived to be of little value at home.

Edinburgh-based recruitment company Head Medical has noticed an increase in enquiries from junior doctors looking to work abroad. Its managing director Gordon Adam says they initially targeted more senior doctors "but we started to get calls and e-mails from junior doctors who couldn't find quality roles in the UK."

Head reports it has placed doctors in the Antipodes at a rate of approximately one a week since January.

Job location is also a problem. Rather than apply to a specific hospital, doctors apply to work in Scotland and if they do well enough at interview they may be allocated to their preferred location.

Although it is possible to link applications with a partner, couples often find themselves working in disparate regions, and because applications are only processed once or twice a year, transfers to be with family typically take years. Many couples, rather than stay apart in Scotland, are choosing to work abroad where they can experience a new lifestyle and live in the same city.

Dr Conway Morris says: "Flexibility is required to allow doctors to pursue specialist interests, research and time out for family commitments. There is a need for the return of Scottish pragmatism, with a realisation that a happy and well-treated workforce are more likely to stay in Scotland in the longer term."

He is also concerned that the shortage of training programmes may prevent the return of doctors from foreign climes, adding: "If there is an increase in the number of apparently dead-end jobs, or if doctors believe they will not be training to become consultants and general practitioners, then I would expect to see a significant increase in the numbers leaving Scotland.

"Were these problems to persist, many may decide not to come back, which would be a serious blow to the Scottish health service and Scottish patients".

Changes to the doctors' job application process have a knock-on effect on healthcare provision. Dr Miles Witham, a Tayside geriatrician, says that because all posts are allocated together en masse, filling vacant posts is difficult: "The trainees all start work in August, so if a trainee leaves the post after a month the job remains open for 11 months until the next round of trainees start. The vacant jobs are advertised, but not as training posts, and because of this people are reluctant to fill them."

According to Dr Witham, such vacancies leave gaps in provision of patient care: "In the previous system, if someone left, the training post would be re-advertised and filled rapidly. Now, after all training posts are allocated, many without a job go abroad leaving few locums to fill gaps."

Scotland is already an exporter of doctors. If more doctors leave, who will be left to provide our healthcare service? The obvious answer is, although remaining doctors will be officially compliant with the European Working Time Directive, many will work considerably longer hours out of a duty to their patients. Perhaps the 48-hour week for junior doctors really is a pipe dream.

&#149 Justine Davies is a doctor and medical writer