The NHS is facing an existential crisis, the shadow health secretary Wes Streeting said last week. The health service needs to ‘reform or die’. Cue the backlash.
How do we keep medical students in the UK without inadvertently funding doctors for other countries?
Sam Tarry, the recently-deselected Labour MP, expressed ‘dismay’ over his colleague’s comments on the health service, while Diane Abbott has warned her Twitter followers that Streeting is ‘trying to push for a privatised/insurance-based NHS’.
After his remarks, the shadow health secretary admitted that he was now out of favour with several of his Labour party colleagues, but said he had received ‘some kind words from unexpected sources’ – namely writers in the Times and Telegraph – following his speech. And he hasn’t yet tried to pedal back on his ‘reformist’ ideas, holding a question-answer session at centre-right think tank Policy Exchange on Friday, titled: ‘A roadmap to double medical school places.’
Last Friday was also the first time that nurses in England and Wales took part in industrial action in the history of the NHS. Eager to avoid tiptoeing past the elephant in the room, Streeting opened on this. He blamed the strikes on ‘12 years of failure to get our economy growing, 12 years of pay freezes and cuts’. He spent four years on the Treasury Select Committee and couldn’t ‘remember the Bank of England monetary policy committee ever blaming poor growth on an NHS waiting list’.
But while his speech was, as to be expected, extremely critical of the Conservatives, Streeting didn’t go much easier on the NHS. ‘When the NHS is failing patients, as it so often is today, it hurts us all,’ he said. Half of those on the seven million long waiting list are of working age, he continued, and ‘the cost of the NHS not delivering the standards of care that patients deserve’ mean these people cannot live their lives to the full.
Streeting has endorsed a Policy Exchange report, written by Dr Sean Phillips and Iain Mansfield, which presents a seven-step outline to expand the number of UK medical school places. Addressing the doctor shortage facing the health service, Streeting agreed that the government should commit to doubling medical student numbers, ‘to enable 15,000 medical students a year to enrol on courses in England by 2029’. This should feed into existing plans across Scotland, Northern Ireland and Wales and, by 2040, the report predicts this would result in an additional 45,000 doctors. While the suggestion of increasing medical school places is by no means an original one, the shadow health secretary believes this would present further opportunities to ‘modernise curricula, incorporate new technologies and training techniques’ and find ‘a new balance between generalism and specialism’ in healthcare.
Labour’s plan would additionally involve training up 5,000 new community health workers a year as well as focusing on fair pay and working conditions to ensure care workers don’t walk out.
Of the seven ‘critical pathways’ that form the cornerstone of the Streeting-endorsed Policy Exchange report, ‘diversifying the talent pool’ is one. This could be achieved, for example, by letting in entrants with lower grades but higher scores in relevant entrance exams, and improving access for applicants from underprivileged backgrounds and underrepresented groups. The idea is not new – Glasgow University is one of many institutions in Scotland that employs a ‘Reach’ programme for those applying from more deprived areas – but broadening entry requirements by accepting that capable, bright students are not necessarily represented by their grades is definitely one helpful, if obvious, way of expanding the course intake. There are always going to be worries that this will lower the quality of graduating doctors, but as long as university standards do not fall, this should not be the case.
The report contains several other interesting recommendations. Accompanying the drive for more medical students is a requirement for more medical schools in ‘under-doctored’ areas of the country. This mirrors the University of Cumbria’s recent partnership with Imperial College London, resulting in plans to build a new medical school in Carlisle. More medical schools mean more medical teachers. The report highlights the need to incentivise more doctors, particularly recent retirees, to stay involved in medical education. And with medicine courses becoming increasingly clinical, deaneries and medical schools should be encouraged to work together to ‘strategically plan’ the allocation of medical school placements in GP practices and hospitals.
None of these ideas are particularly groundbreaking, as one audience member pointed out. And while Streeting’s focus on medical school places is a start, there are still some pretty big questions unanswered. The implementation of his plan would cost at least £1.2 billion between 2024 and 2029. One way of supporting ‘the financial viability of [this] expansion’ may be, the plan suggests, to increase the proportion of international students studying medicine at UK universities – from 7.5 per cent to 10 per cent. While increasing medical school places will logically lead to more doctors graduating in the UK, international students often return to their home countries, or work abroad elsewhere soon after they qualify.
That’s not to mention the number of British doctors that are moving elsewhere – often Australia – to work after they finish their foundation training years. In 2011, the UK provided Australia with 13 per cent of its GPs and 22 per cent of its specialists. Six years later, a 2017 report by the BMJ found that the number of British doctors working overseas in Australia and New Zealand was continuing to rise, with a 17 per cent increase between 2014 and 2016.
There’s a massive retention issue in medicine, and a lot of my former classmates are planning to move out to Australia after they qualify. Some are already out there. I pushed Streeting on this at the Policy Exchange talk: as much as we want to bring in more medical students, how do we keep them in the UK without inadvertently funding doctors for other countries?
‘Over the next few years, there will be more to say not just on recruitment, but retention and return,’ Wes Streeting responded. (Here, ‘return’ refers to the drive to bring back doctors who have left the health service to help ‘plug the workforce’.) But there clearly isn’t too much that Streeting can offer on this right now. In fact, while it’s evident the shadow health secretary has spoken to a vast number of healthcare students across the UK – including those on nursing and midwifery courses – understanding the reasons why newly-qualified doctors want to leave the NHS, after receiving their medical degree, is far lower on his priority list. Wes Streeting seemed convinced that creating more junior doctor places would encourage current medical professionals to stay put. However his plan doesn’t appear to account for the obvious time lag between the increase in medical school places and its reflection in workforce numbers, or the aforementioned international student dilemma.
Undoubtedly, there are many positives to be taken from Streeting’s proposals. Medical school curricula have evolved dramatically over the last 30 years and focusing on the development of clinical and simulation-based teaching will only help better prepare medical students for hospital work. Considering new approaches to help applicants gain access to medical courses is vital. But for the NHS to be reformed in a way that prioritises its patients while keeping healthcare staff on side, politicians need to better show how the solutions they offer will actually help, in real, practical terms. And they need to fully understand the problems faced by healthcare workers if they want to retain them. Right now, I’m not convinced that they do.
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