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How Britain became a terrible place for doctors

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In some ways, Britain’s doctor shortage resembles the worldwide crunch in healthcare. From France and Germany to the United States, Spain and the Nordics, ageing populations are increasing demand for doctors, nurses and care workers. Yet medical training is expensive, the number of training placements for graduates is limited, and the pandemic has left many doctors spent.

When it comes to Britain, imagine those pressures on steroids. At the end of last year, there were about 124,000 healthcare vacancies in England; of these, nearly 9,000 were doctors, although that surely understates the extent of the problem. By 2030, one in four general practitioner posts are estimated to be vacant.

There are multiple factors at play here. Some 18 per cent of GPs reach minimum retirement age in the next year to ten years. There has been increased attrition, with the number of doctors who retire early trebling in the past 13 years. The country trains too few doctors and then rewards them with low pay and poor working conditions — the focus of recent strikes. Meanwhile, the taxpayer-funded National Health Service is straining under a Covid backlog that now stretches to more than 7.4 million procedures, with consequences for everything from cancer care to hip replacements.

Doctors I have spoken to — even those who are long-established in their fields — say it is getting harder to be a doctor in Britain. But while government policy has focused on recruitment, the bigger issue is retention. It is no surprise that so many young doctors are opting for life elsewhere while their senior counterparts are retiring, curbing hours or focusing on more lucrative private practice.

Australia, which is facing acute doctor shortage of its own, is aggressively recruiting British doctors, whose accents are now ubiquitous on wards in Perth, Melbourne and elsewhere — eg, on TikTok, regaling their British counterparts about the lifestyle benefits Down Under. Every “junior” doctor I’ve spoken to — a designation that applies to registered doctors with as many as eight years of experience — has classmates and friends who have moved abroad for higher salaries, better quality of life and less stressful conditions.

“I spent more time trying to find a space or bed to see a patient, finding equipment or firefighting logistical issues than doing the thing I was trained for,” one senior emergency-room doctor who moved to Australia with her medic husband told me by e-mail. They looked around and saw a system that was only getting worse. “Close colleagues were having strokes, heart attacks and breakdowns in their forties and fifties. We wanted to make sure we were around for our children.” Like many of the doctors, she spoke on condition of anonymity.

Thomas Brockwell, a junior doctor who did his training at Oxford University, is just finishing his first year of postgraduate clinical work in Britain in hopes of becoming a paediatrician. He describes his office as a three-metre-squared room that he shares with two other doctors. Between them, they have two “useable” computers and not a single unbroken chair. From midday, when the senior doctor leaves, this trio will run the ward; outside the hours of 9am to 5pm, they will oversee 11 wards — or some 250 patients.

“I have been spat at, punched, leered at and groped,” says Brockwell, who takes home £35,000 (about $43,450) before tax, less when his “Sisyphean graduation present” of £100,000 of student debt and living expenses from six years of training are deducted.

Of course, doctors everywhere endure many of these indignities, along with unsociable hours. In some countries, though, compensation levels ramp up quickly and working conditions are considerably better. One junior doctor in Britain notes she has to pay for her own scrubs, pay to access the “doctor’s mess” and pay for parking — small snubs that contribute to a sense her employer has little regard for working conditions and what they cost. And lest this workforce seem small, they account for nearly half of all hospital doctors in England.

There are political and cultural debates about whether Britain’s junior doctors are really so badly paid, even at starting salaries of about £14 an hour. Much of their medical education is taxpayer-funded and doctors can usually supplement their basic wages with more highly paid temporary locum work, as opponents of increasing doctor pay have pointed out. Employer pension contributions in the NHS, at higher than 20 per cent, dwarf the average of about 6 per cent in the private sector and doctors receive defined-benefit pensions, which are now rarely seen outside government.

Yet such arguments miss the point. If the NHS is losing senior doctors to early retirement, private practice or burnout, and also watching newly trained doctors move abroad or forgo specialist training for a better deal, then the labour market is not working to meet demand. The result is a depleted workforce, low morale and poorer quality of training for new doctors. And that’s not to mention a spiralling healthcare crisis that shows no signs of ceasing.

The British Government is hoping to plug the hole by creating apprentice doctors, who would bypass traditional medical school and be paid to work in clinical settings. Provided they pass the requisite exams, they would qualify as doctors five years after secondary school and with none of the debt that so many traditionally trained physicians incur. You can imagine how that has gone down among junior doctors.

Many of us would say that we could live without a lot of what we learnt at university or that we have learnt our trade mainly on the job. But doctor training requires a bedrock of scientific knowledge acquired through years of study. Would the apprentice degree really equate to that of a medical school graduate? Would it create a two-tier system of doctors?

It may also exacerbate existing pressures. The British system relies heavily on senior doctors to pass down experience on the wards to those in training, but both the capacity and goodwill required for this to happen are now in short supply. Medical students often have to chase down and practically beg to observe senior consultants who no longer have the time for this role. Apprentice doctors would be more competition for those limited resources.

It is possible that the advances of artificial intelligence will lead to a radical rethink of medical education, with the prospect of time and resource savings and a lower bar for entry. But given existing NHS conditions, the government plan is like putting a Band-Aid on a bullet wound. One senior London-based surgeon told me the plan smacks of trying to create a cheap labour force of individuals who will do low-level jobs in hospitals.

There are no easy fixes here, in part because the problem reflects the deep structural flaws in the NHS itself. The gradual increase in the number of medical school places is too limited to plug the doctor shortfall. But that is not likely to change much, both because of funding constraints — the Government estimates that each place costs about £230,000, of which some £65,000 is paid to the student in loans that are recovered over the course of their careers — and capacity limits on ward-based training. Britain certainly needs to train more doctors, but that requires keeping more of those it already has.

Like Australia, Britain is importing a record number of foreign doctors to fill the gap. Of those who joined the workforce in 2021, half were trained outside the UK. By 2030, internationally trained doctors would make up more than two thirds of the workforce under present trends, with the largest numbers coming from South East Asia. But even that is not sufficient to make up for shortfalls. And internationally trained doctors are more likely to move on for better pay or conditions.

British doctors in Australia and New Zealand cite a better working environment, higher staff morale, two to three times the pay of British practice, greater control over hours and more respect for the profession. “In the three emergency departments where I work in Sydney, 50 per cent of the doctors are UK-trained, and in some it’s over 70 per cent,” says the formerly London-based emergency-room doctor now in Australia. Some come for a few years and return, she says, but most stay.

Most British-trained doctors do not want to leave their country, but the advantages are hard to ignore. With so many places fishing for doctors and other healthcare professionals, this is a labour force that will be more mobile than ever before. At the moment, Britain’s brain drain is Australia’s doctor gain.

Therese Raphael is a columnist for Bloomberg Opinion covering healthcare and British politics. Previously, she was editorial page editor of The Wall Street Journal Europe

Therese Raphael is a columnist for Bloomberg Opinion covering healthcare and British politics. Previously, she was editorial page editor of The Wall Street Journal Europe

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Published May 23, 2023 at 8:00 am (Updated May 22, 2023 at 4:45 pm)

How Britain became a terrible place for doctors

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