Dr Rob Sutton is an incoming junior doctor in Wales and a former Parliamentary staffer.
There has been a major decline over the last decade in doctors moving directly from foundation training to specialty training – a trend which the Health Secretary can correct before the next general election.
The length of a parliament can be a barrier to achieving lasting change in the NHS. The five-years of a parliamentary term is approximately the same length of time it takes to complete an undergraduate medical degree, a blink of an eye in terms of the working life of a healthcare professional.
A government which places NHS staffing issues at the centre of its manifesto pledges risks bearing the costs without reaping the political rewards in time for the next general election.
Yet this is the framework within which our Government operates. Incumbents must find political wins they can implement and present to the public by the next general election.
Commendably, NHS staffing was placed at the centre of the 2019 Conservative manifesto, with the pledges to train 50,000 more nurses and provide 50 million more GP appointments per year by 2024/5.
The disruption caused by the Covid-19 pandemic has made achieving these pledges considerably more difficult. The number of nurses in the UK fell between 2019 and 2021 (although this is part of a global trend), as did the number of GP appointments.
While there are factors clearly beyond the power of the Government at work here, there remains a need to demonstrate concrete achievements come the next general election. In my experience, the public have been extremely understanding about the delays and barriers to healthcare access imposed by Covid-19, but this will eventually wear thin.
Coupled with the looming NHS backlog and the risk of a major exodus of staff following the pandemic, and the 2019 pledges risk look more like a major liability. This is a matter to which national power should be brought, particularly as Sajid Javid’s hand is strengthened by the passage of the Health and Care Bill through parliament (it enters its Committee Stage in the Lords on 11 January).
So where should he be looking? The entry of doctors into further training would be a sensible starting point, not least because it can be implemented within the current parliament, would have minimal cost (and bring potential providing savings) to the taxpayer, and provides an attractive achievement to present at the next general election (“We have X per cent more doctors progressing through training than five years ago!”).
In the UK, upon completion of medical school, most graduates enter a two-year programme of training administered by deaneries known as the Foundation Programme (FP), in which foundation doctors complete six four-month rotations across a range of specialties.
Upon successful completion of the FP, those doctors may then enter a specialty programme, such as internal medicine, core surgical or GP specialty training. Entry into these programmes is via a competitive application process, usually involving an initial points-based application followed by further interviews or competence assessments.
It is this transition, from foundation training into specialty programmes, which will provide the next generation of senior doctors for the NHS. In 2009, the proportion of doctors completing the FP and progressing directly into specialty training was 85 per cent. By 2020, this figure stood at 31 per cent – a fall of almost two-thirds.
It is worth seeing the graph for oneself to truly appreciate the decline. Where are these doctors going? And why are they no longer progressing straight into specialty training?
Some leave medicine permanently or decide to practise abroad. The majority take up what is known informally as a “foundation year 3,” an extra year of either locum work or clinical fellowship, ostensibly to gain further experience before entering specialty training.
What’s the problem with an extra year to decide on the specialty which you could be practising for the next 40 years? Shouldn’t we be encouraging doctors to make a well-informed choice? I find this argument unconvincing for two reasons.
First, after five years of medical school and two years of foundation training, it isn’t evident that an extra year outside of formal training will bring a conclusive decision. Major choices like that have a habit of being kicked down the line. Second, as doctors leave and experience the benefits of life outside of training, there is a chance that they stay out of training even longer, or perhaps permanently.
The problem is that we have a system with strong incentives to leave training, and limited reasons to remain. Entering specialty training involves intensive preparation, tight deadlines, costly examinations, limited geographic choice, fixed timetables, and major professional commitment. In contrast, locum work generally does not and is more lucrative. Many junior doctors find themselves asking “Why on earth would anyone go straight into specialty training when I can easily take up a locum post?”
It is also a system which perpetuates itself indefinitely. A doctor leaving training creates new demand for a locum to take their place. But we can’t build the NHS on locum work. Doctors need to have a stake in a place and a sense of ownership in the work they do. Without this, there is little incentive to engage in long-term quality improvement projects through audit, research, medical education, and trials.
The Health Secretary is fortunate that he has the power to tackle this problem immediately. Locum rates should be capped nationally. Entry points to training should be increased throughout the year. Completion of at least one examination during the FP for specialty entry should become the default. We need to normalise a smooth passage through training and move away from the hand-to-mouth provision of healthcare provided by a system increasingly built on locum work.