For years, Britain has been failing to train enough doctors and has been importing them instead. This has been a well-known and much lamented fact, raising several ethical issues. Is it right for us to rob developing countries of their much-needed medics? Simon Stevens, the head of the NHS, said at the Spectator’s health summit this week that Britain should stop ‘denuding low-income countries of health professionals they need’. Quite so.
Which makes it all the more shocking that last year, for the first time ever, the UK imported more doctors than it trained. And the problem Stevens highlights has, under his leadership, been getting steadily worse. Look at the number of new doctors registering with the General Medical Council: three years ago, 44 per cent were foreign-trained. Last year, it was 53 per cent. Last summer, the government announced the removal of the cap on skilled workers entering the UK (the Tier 2 visa cap) for health workers. As a former NHS surgeon, I can well imagine what will now happen: the number could be as high as 60 per cent within two years.
To make matters worse, there’s growing evidence that an increasing number of our own trainees are leaving the profession — or choosing not to progress to speciality training. The convergence of these two factors is a recipe for disaster and there’s that moral problem too, given that foreign doctors invariably come from low-income countries, and have been trained at public expense. We’re poaching medics from places where they’re badly needed.
Why are our home-trained doctors leaving? It could be the conditions. They are often thrown in at the deep end after two years of training, looking after up to 60 patients on a 12-hour night shift, often alone, with inadequate handover or senior support. It can be a lonely, brutal experience, and some young doctors never recover.
Not surprisingly, recently published figures confirm the resulting level of discontent among trainees. Nine years ago, 83 per cent of the young students who had been through the first two years of general postgraduate medical training entered speciality training. The proportion has now fallen to 38 per cent.
I’m afraid that much of the damage to trainee morale lies at the door of Jeremy Hunt. As the longest-serving secretary of state for health, he provoked an unnecessary junior doctors’ strike based on a false premise. He wrongly blamed 11,000 ‘unnecessary’ weekend deaths on junior doctor rostering — which left them understandably demoralised.
Where do the foreign doctors come from? Despite fears over Brexit, the number coming annually from Europe (by which I mean the European Economic Area) has been constant: just above 2,000 for the past three years. Primary medical qualifications are reciprocally accepted across Europe and no competence or skill checks are required, although you have to speak good English. All told, there are about 31,000 EEA doctors registered to work in the UK and they mostly come from eastern Europe or from those southern European countries worst affected by austerity. Very few doctors come from affluent western European countries. It makes sense. Why would a French doctor want to work in an inferior health service?
The other incoming foreign doctors — or international medical graduates — are mostly from Pakistan, India, Nigeria and Egypt, though the full list of countries is long. And it is set to grow longer with the abolition of the visa cap.
Quite apart from the fact that their own countries need them, the trouble with many of these countries is one of competence. To register with our General Medical Council, non-European doctors must pass a test for skills, knowledge and basic English: the Professional and Linguistic Assessments Board examination.
It’s hardly a major challenge, but the pass rate of the various parts has been worryingly low (50-75 per cent) and candidates can take the exam up to five times. In addition, two articles in the BMJ have shown that doctors who do pass subsequently fare significantly worse than British graduates in the two most common postgraduate exams. The authors conclude that the pass mark should be raised considerably — but that this (they put it politely) would have ‘implications for medical workforce planning’.
During his period of apology, remorse and repentance following the crisis in the winter before last, Hunt made several announcements intended to restore his political credibility. There would be an extra £20 billion over five years for the NHS, 3,000 new midwives (where will they come from?) and five new medical schools intended to increase the output of medical students by 25 per cent, so that the UK would be ‘self-sufficient in doctors by 2025’. Given current trends, this looks laughably unrealistic.
So how are we to fix the problem? Medicine is a tough profession, requiring stamina, resilience and a determination to succeed against the odds. In my day, adequate A--levels, a good headmaster’s report and proof of leadership or another impressive achievement would guarantee a medical school interview. In other words, selection was character-based. Selection is now entirely academia-based. Students need four A*s at A-level, success in unproven aptitude tests, evidence of work experience arranged for the purpose and a manicured personal statement to make the grade. It’s not clear that these are exactly the skills they need to flourish in what everyone agrees is a harsh environment. There is no evidence that super-clever students make better doctors.
Junior doctors need to be tough — but they should also be better supported and better supervised as they learn to manage life-or-death situations for the first time. It’s not fair to treat them as work monkeys, responsible for menial and routine tasks, and in the end it’s counterproductive. A solution must be found, because the endless importing of foreign doctors is not the answer.
Now listen to Meirion Thomas with Saffron Cordery, Deputy CEO of NHS Providers, on the UK's doctors shortage (16:00):