The Department of Health (DoH) is proposing to lock newly qualified doctors into working for the NHS for a period of time, potentially 5 years. This “Medical Conscription” policy will see doctors who quit working for the NHS before the end of that lock-in period “paying back” the cost of their training. The public consultation on this matter will close this Friday 2nd June 2017, and I urge any medical student or doctor reading this to voice your opinion via the DoH Online Survey. As a medical student or a doctor, you like no one else will know what disastrous consequences such a policy will have on the medical profession as a whole, and on doctors as individual human beings in particular.
Whether doctors leaving medicine have wasted taxpayer’s money has been recently written about by the author as well as by Dr Michael Brooks. With thanks to Dr Tariq Mudassar, here’s some relevant number crunching. For simplicity, let’s say it takes £150k to train a doctor (the government claims it’s £230k with another source explaining why it’s closer to £163k). After qualification, most doctors will have worked at least some years with the NHS. Now let’s look at comparable professions such as accountants or lawyers who can charge £250 per hour. That would mean a doctor who works 6 hours a day would be doing £1500 worth of work for the NHS daily. So it would only take 100 days (or 3 months) for the NHS to recoup their money back.
Interestingly, in the online consultation the question about a proposed “minimum term” offers a choice of only 2, 3, 4, or 5 years.
There is no option to choose zero years or one year. I suspect the design of that question will ensure that they can later report that 100% of those surveyed agreed that at least 2 years conscription was appropriate pay back to the taxpayer.
When considering medical conscription, the government’s proposals are vague in defining what will constitute “NHS service” for the UK medical graduates. The Telegraph mentions that there “would be some exemptions [so that] doctors might not have to repay costs, such as for those on maternity leave” but the official source does not mention this.
More questions than answers
Now, let’s assume the lock-up period is 5 years.
Will this time need to be “served” in consecutive years?
Does it have to be in a training programme, or could a doctor work in a stand-alone NHS post such as a one-year fellowship? How about “serving” as a locum at an NHS hospital – would that count?
What about taking time out of clinical practice for further study (e.g Masters, PhD), which often leads to a decision to continue in academic research? Will academic research at an NHS-affiliated institution count as NHS service?
What will happen for doctors moving to a developing country to do charity work and staying there for several years?
What about taking time out to travel, to have a family, to run a business, to embark on one of those Leadership Fellowships that everyone talks about these days? Would a doctor be “forgiven” for taking a career break to pursue this non-clinical role?
What if a doctor works one day a month (e.g. as a locum) to maintain their clinical skills while developing a “portfolio career” – could they do this for 5 years and leave? Or, would that period of time be recalculated pro-rata, and they’d be potentially stuck with NHS service for the rest of their life?
Will doctors be “allowed” to work part-time? Will their clinical work at a non-NHS institution count? Do they have to be treating patients directly to avoid the fine (let’s not forget that public health physicians don’t treat patients directly)? How much parental leave, leave on health grounds, or any other leave would be “forgiven” and counted toward the 5-year service?
What about doctors who have “failed to progress” and the outcome of their ARCP or revalidation is in fact a recommendation to be discharged from NHS service. Would such a doctor have to pay back the taxpayer’s money? How about doctors under investigation by the GMC – would that period of time count toward the 5-year “service”? What if the doctor is struck off within that time frame – would they still have to pay back?
There is no explicit contract with a student when he/she starts medical school. Why has Jeremy Hunt decided that a medical graduate can ONLY work as a clinician in a hospital or a GP practice? There are many worthwhile career paths that someone with a medical degree could take, which would directly contribute to the state’s economy (through tax) and indirectly to patient care, making the taxpayer satisfied that their money wasn’t wasted. I agree with Aman Coonar who said, “a medical degree and medical training provides lots of generic skills which can be applicable and benefit wider society. It’s important that medically qualified people pursue other careers. They bring their insights of medicine and some of those values and principles that attracted them to medicine in the first place”. What about doctors like Aroon Baskaradas who stepped away, got a fresh perspective, then came back and loves his NHS job? Would such doctors be eligible a refund?
There are more questions than answers. You should voice your opinion before it’s too late and an ill-thought out idea starts ruling doctors’ lives.
The wider impact of medical conscription
Most medical graduates will amass debts of more than £80,000. I recently wrote at length about the current dismal situation with the prevalence of mental health issues and suicide in the medical profession. If a lock-in NHS service period is enforced, I foresee a significant increase in suicide rates among doctors who can neither afford to pay back for their training (on top of student loan and other debts), nor to continue working as a doctor (for whatever reason).
Leaving clinical practice is not a decision taken lightly by any doctor. There will often be many other difficult things to consider like children to provide for, personal financial liabilities, impact on relationships, and personal health issues. As Pawan Mathur said, “medicine is a vocation; to recognise it’s not for you and step away from it requires insight and courage”. I believe that in making this step, a doctor actually does a favour to the public.
Also let’s not forget that the vast majority of degrees cost the taxpayer but do not result in civil service. Why isn’t the government thinking about recouping the taxpayer’s investment from History graduates who don’t become historians or Geography graduates who don’t become geographers?
My proposition to the government
Instead of wasting taxpayer’s money on bringing this proposal to life (and thus only very superficially addressing the public interest in having adequate workforce), I would suggest the government uses valuable resources
(1) to investigate in depth all the factors contributing to doctors leaving, and
(2) to set up proper processes, mechanisms and incentives for talent retention.
On the first point, as far as I’m aware, there is no single region in the UK at present where they would systematically look at their leavers (trainees or non-trainees) and follow them up to get data for detailed analysis. This would shed much light on the root cause for people making such a life-changing decision after much personal and taxpayer’s investment.
Doctors are human beings. By choosing to study for 5-6 years at a medical school they would’ve made a big sacrifice in terms of their family life, relationships, wellbeing and financial implications. If the government wants to handcuff them to the NHS service, it should provide adequate work conditions. Greater availability of opportunities to work part-time and free food when doing oncalls would be a good starting point. I have many more views on improving talent retention, which I will write about separately.
A society’s view of suicide changed over a hundred years ago when Emile Durkheim wanted us to think of suicide as a societal issue rather than an individual problem. In the same way, argues Tariq Mudassar, should we not think of doctors who leave medicine as a societal issue, that is looking much more broadly at the general factors that cause doctors to leave medicine. Let’s face it, medicine is still a well paid job. The fact that doctors would leave this profession (often to do something that pays less) says a lot about the conditions of work and a bigger impact of this career on doctors’ lives than may be obvious to the public or the government.
So, run, doctors, run, and give your views to the DoH until it’s too late.
P.S. Since publishing this article, I’ve been made aware that Jack Haywood has also written a piece on this subject. It’s well worth a read.
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DISCLAIMER: The opinions expressed in this article are my own, and not necessarily those of my past or current employers.
