The Current Challenges Facing Trainee Doctors in England
Generations of Irish doctors have travelled to England in to obtain training and experience. For most it has been a very valuable and successful career move. In general, English training schemes have been held in high regard by Irish doctors. Thus, it is clear that factors affecting English trainees are also important for young Irish doctors contemplating working in the NHS for a period of time. In the Medical Council’s survey, 32% of NCHDs who leave Ireland go to the UK. However, all is not well in the NHS. In recent times English trainees have become increasingly dissatisfied with their working conditions. The problems have been building for some time.
Since 2012 the NHS and the BMA have been in negotiations towards a new contract for junior doctors1. In Oct 2014 the BMA junior doctors committee walked out of negotiations over a new contract. This step reflected the sense of frustration felt by junior doctors about their training and working lives. They were concerned about inflexible placements, training requirements, and roster allocations. The proposed plans for a 7-day service was the catalyst for protests and action. Matters deteriorated further in August 2015 when England’s health secretary Jeremy Hunt announced that he would be imposing a new contract. Relations were further soured by his misuse of weekend mortality statistics and by his statement that doctors lacked commitment.
In October 2015 there were street protests by thousands of doctors. These received wide media cover. In January 2016 junior doctors began a series of strikes. In was the first such industrial action in 40 years. In May 2016 the BMA negotiated a revised contract. Although the new contract was endorsed by the chair of the junior doctors committee, it was rejected in a subsequent ballot. The doctors felt that many issues affecting their working lives remained unresolved.More recently, a group of 5 junior doctors (Justice for Health) took a high court action against Jeremy Hunt2. They contended that he was acting outside his legal powers when he announced that he was imposing the new contract after it had been rejected. However, Mr. Justice Green found in favour of Mr. Hunt. He ruled that Hunt acknowledged that he had no power to impose the new contract. Mr. Hunt was approving the contract but not compelling employers to adopt it. However it is known that he has achieved consensus with employers that the proposed new terms and conditions represent a fair and workable basis upon which to proceed. The junior doctors committee has stated that the ruling will do nothing to reduce doctors’ fears about the imminent introduction of a flawed contract that they have already rejected. The sense of anger and mistrust persists. The problem facing the doctors, however, is that all the power sits with the NHS is a powerful, monopoly employer.
Neena Modi3, president of RCPCH, has stated that the ruling is the latest twist in a long drawn out damaging dispute. It has brought thousands of doctors on to the street to protest. Junior doctors were driven to industrial action for the first time in many decades. The breakdown in the relationship between the Government and the trainees represents a catastrophic failure of senior leadership at all levels. Modi points out that the pace of costly, untested reorganizations is extraordinary. Funding is at an all time low and services are being withdrawn. The junior doctors’ protest is an expression of breaking point frustration with their training and a wake up call to the true state of the NHS. She goes on to state that there is a need to restore trust and morale. Young doctors must be respected and treated as professionals. The imposed contract is damaged goods. It should be discarded and replaced with one drawn up on a clean sheet.
On October 4th Hunt announced that he was increasing the number of medical students by 25%. From Sept 2018 England will train up to 1500 more doctors every year4. The aspiration is to expand the number of home grown doctors and to replace doctors recruited from overseas. The number of medical school places currently stands at 6000 per year and has decreased by 2%. Commentators have pointed out that the expansion in student numbers will take at least 10 years to have any effect. It will require the creation of new medical schools or the expansion of existing ones. There is also criticism of the proposal to ‘conscript’ newly trained doctors to the NHS for 4 years unless they repay part of the cost of the £220,00 to train them. The key to keeping doctors in the country is to develop the right training environment for them. Trainees need to be supported and valued rather coerced. Fiona Godlee, BMJ stated that penalizing trainees who leave the health service is ripe with unforeseen consequences. It represents playing to the gallery rather than tackling the more fundamental problems in the NHS.
Another proposed measure is to charge overseas medical students the full cost of their training. This may be counterproductive and reduce international students interest in coming to England. There has been considerable correspondence about the large contribution that foreign doctors have made to the NHS. Overseas doctors currently make up 25% of the workforce. They have added to the exchange of ideas, skill sets and knowledge between countries.
What appears to have been forgotten by the authorities on other side of the Irish sea is that junior doctors are at a vulnerable phase of their career and their lives. Anxiety and uncertainty are common sentiments among trainee doctors. Their jobs are without security of tenure. Their future in the profession is dependent on passing postgraduate exams, displaying clinical efficiency, and making a suitable impression on their senior medical supervisors. Support, mentoring, encouragement, and mutual trust are key components in a good postgraduate training programme.
Recently, Cork University Hospital (CUH) published a Charter to improve junior doctor’s conditions. Mr. Tony McNamara, CEO at CUH, said that in Cork EU compliance is 96% for shifts and 80% for the 48 hour week. The unmeasurable is the quality of the relationship between hospital management, consultants, and trainee doctors. Colm Henry pointed out that in the past NCHDs had not been fully respected or valued. The overall conclusion is that there must be continued planning and investment in the training of junior doctors.
1. Moberly T, Rimmer A. How the BMA lost control of the junior doctors’ dispute. BMJ 2016;345:i5266
2. Dyer C. Junior doctors lose legal challenge over contract imposition. BMJ 2016;354:i5300
3. Modi N. Junior doctors dispute leaves big questions about state of NHS. BMJ 2016;355:i5432
4. Torjesen I. Hunt aims for fully home grown doctor workforce. BMJ 2016;355:i5399