Stephen Bradley: The NHS workforce—fix the leaky bucket before turning on the tap

Increased staffing is welcome, but only addressing the crisis in morale can stem the attrition crippling our medical workforce. Many improvements can be made without additional spending

Jeremy Hunt’s announcement last year of 1500 more medical school places is one of the health secretary’s only policies that’s been met with (cautious) welcome by doctors. Desperate as we are for greater numbers to prop up one of the most under-doctored health systems in Western Europe, it will still be over a decade before these new recruits become senior clinicians. Meanwhile, year on year we lose more trainees—most will eventually return, though many will not.

Many of the remedies that have been suggested—from imposing medical conscription, to girding doctors’ emotional responses with military style “resilience” training—seem informed by the assumption that improving conditions is too hard, or expensive, to consider. Yet all around us there is much that could be done—by both individual trusts and national bodies—to improve morale and training, even without additional funding, if only the will was there.

These possibilities for improvement can often be found in the small, simple things and can be acted upon locally. By providing basic amenities, such as rooms for rest and access to meals and by humanising their human resources departments, NHS trusts could win a sense of belonging and loyalty from their doctors, who so often feel that they are just “passing through.” Trusts should embrace the opportunity to enhance quality and safety by attracting doctors through a positive reputation.

Currently most trusts also seem to demand hours of annual e-learning completed in doctors’ unpaid time, “just in case.” This needs to stop. Employers who do not rein in, or pay for, inductions dumped on their doctors’ leisure time should expect to be forced by their trainees and guardians of safe working to pay out through exception reporting.

On top of this, and while meeting impossible service pressures, doctors also have to satisfy the demands of training bodies, which is an important contributor to plummeting morale. We have been promised a welcome move away from the exhaustive lists of “tick box” competencies, and it’s important that colleges and the General Medical Council (GMC) follow through on this. It would take bravery to no longer ask for “sign offs” on every single skill, such as venepuncture, but it’s time to accept that this demanding requirement achieves little in the way of improving quality, but does much to denigrate the training (and trainers’) experience.

Furthermore, successfully navigating the clunky and compulsory online platforms where this learning is logged (“e-portfolios”) currently feels like an interminable game of battleships in which the player must hit the right combination of box clicks with the aim of avoiding an ARCP summons. E-portfolios should be simplified and their improbably high fees reviewed. The e-portfolios’ ubiquitous “reflective entry” was previously resented for being just another time consuming annoyance. Yet reflective entries have now acquired a more sinister dimension in the wake of the Bawa-Garba case and the use of these entries as an instrument of blame in court. That colleges continue to insist on sincere reflections while acknowledging that these could be used against doctors in court is not acceptable. Colleges should protect their trainees by abolishing mandatory reflective entries.

Several colleges have spoken up for their trainees and have passionately articulated their commitment to juniors as the future of the profession and health service. Yet some of the colleges could follow this up by reviewing their training costs. The cost of training is variable but high across all specialties and there’s a sense of unaccountability for the fees trainees pay. Exam fees can be as high as £1685 for a single exam (£12.96 per minute). Meanwhile, brazen wheezes, such as using trainees’ success in claiming tax relief for exam costs as a justification for increasing fees, contribute to a perception that colleges are acting cynically. Exams may be “cost neutral,” but this does not preclude colleges from having an obligation to offer value for money on the fees that they demand.

Although the GMC’s role is primarily to ensure patient safety, the current crisis in retention that threatens the provision of healthcare should prompt our regulator to reflect on the meaningful gestures it could make. The large, and ever increasing, “retention” fee it levies on doctors is grudgingly accepted, but adding an extra charge for paying by direct debit strikes most people as unfair and unusual. Furthermore, while the cost of private healthcare cover for GMC employees at over £200 000 is admittedly a small portion of the organisation’s budget, giving this up would be an important gesture of solidarity with NHS patients and staff.  

The GMC could also take issue with the organisations that threaten referral as a standard inducement in all manner of diktats, such as ordering doctors to take on extra locum work. Much more serious is the chill caused by the perception that the GMC is pursuing doctors who fall victim to human error while working in impossible conditions. In other words, potentially all of us.     

Medical morale, and the consequent crippling attrition of valuable staff, is among the most serious threats facing the NHS. More doctors for the future is welcome, but we need to urgently formulate a coordinated plan to improve juniors’ training experience and stem this unsustainable drain of talent. Almost every organisation that interacts with doctors can play a part and deliver measures that need not prove materially expensive, but which will require bravery and leadership.   

Stephen Bradley is a GP and clinical research fellow, having completed training in September 2016. Twitter @DryBreadnRadio

Competing interests: I serve on the GMC’s PLAB part 2 management group and I am a tutor at Leeds Medical School.