It appears from the language used in the consultation that there is a desire to seek justification prior to implementation. A recent poll on YouGov reminds me of the quote “you need to ask the right question to get the right answer.” The heavily biased question: “Under new government plans doctors could be forced to work in the UK for at least five years after completion of training or payback for some of their training courses. This is because many doctors leave the UK after training to work in other countries. It costs the taxpayer £230,000 to train a doctor over and above the fees paid by the individual. Do you think doctors trained here should pay some or all of this back if they leave the UK less than five years after training?” gained a 91% positive response.

H L Mencken wrote “For every complex problem there is an answer that is clear, simple, and wrong.” This feels like the wrong answer to the wrong question.

I think back to my early years post qualification. I worked over 80 hours per week doing a 2 in 5 rota. I was taught medical skills and enjoyed great camaraderie with my colleagues, spending time together, and working as a team. In my first house job, I was on the surgical on call rota and there were many more junior doctors on call in 1991 for a shift than there are now in 2017. My consultants took me under their wing and mentored me about my career plans. I spent four years deciding on my final career pathway and enjoyed my jobs. Although I was tired, I felt valued by the system. There is no doubt that the hours did not suit everyone and the reduction in hours was welcomed by the profession.

Now, trainees are working in an intense and underfunded system where staff do not appear to be valued. The environment developed has forced junior doctors to think twice about their long-term career options. Those that wish to stay are galloping through their first year of clinical practice, developing their portfolios to show baseline competence and a competitive CV for their chosen speciality. To achieve the essential criteria, they need evidence of leadership, management, teaching abilities, audit, and quality improvement projects. They need the ability to convene courses as well as be trained, and also be great mentors and colleagues. And of course, they need to pass the necessary exams. Within 18 months they need to have a concrete career plan and they need to achieve a core training post to have any incremental increase in salary. Team structures have been abolished and junior doctors do not feel part of the team.

It is no wonder that trainees feel demoralised and burnt out. They are coerced (outside of any goodwill left) to cover for absent colleagues due to rota gaps and often need a break after two years in a high-pressure environment. They take time out by going abroad, or explore career options in trust posts or as locums to allow them to test out other avenues whilst they decide on their final career pathway.

At present half of Foundation doctors (2 years post qualification) decide not to continue into a definitive career pathway in the UK. The Government suggests that conscription into five years of NHS service post qualification could improve retention akin to military training. The parallel to military recruitment and retention would be welcomed if the terms and conditions were similar. At present military medical cadets are paid a salary throughout medical school as well as educational fees. These trainees are valued by the military and are resources that are heavily invested in, to ensure they are equipped for service. If a military cadet wishes to leave, they can give notice and are required to pay back any expenses incurred. If similar terms were offered to medical students and doctors, because they are a valued resource which is worth investing in, retention would not be a problem and the discussion of conscription would not be necessary. Yet again, the Department of Health is trying to fix a problem with a sticking plaster rather than understanding the root of the problem.

Would a five year conscription improve the retention of junior doctors? Or will it cause an exodus of trainees after five years?

Are these the right questions, or do we need to ask “Why is there a retention crisis in the NHS?” We need to address junior doctors’ morale in order to solve this.

Stella Vig has been the foundation programme director at Croydon University Hospital for 10 years and holds many roles, including those of core surgery and higher surgery training programme director, JCST chair for core surgery, and general surgery SAC member. She is one of three clinical directors for Croydon and is keen to see efficiency and excellence in patient care within the NHS. 

Competing Interests: I am a member of RCS England Council and a trustee for the Society of Chiropody and Podiatry. 

4 thoughts on “Will making new doctors work in the NHS for five years improve retention? BMJ Blog

  1. This question has been raised at least once in the past.

    I thought then, and I still think, that it is thoroughly disgusting, morally repugnant and typical of any government without the ability to think and who lack any ethical compass: it is a poverty of understanding.

    The question can only be asked because the NHS is a monopoly employer. The numbers of medical students is determined by the NHS years in advance, taking account of what are expected to be the needs of the service and the population — and presumably allowing for some ‘wastage’. This limitation of student numbers is called a ‘numerus clausus’ on the continent, though there restriction seems to be based on the limitations of teaching establishments. Thus, being a medical student carries the implication that you will always work for the NHS; there are other opportunities, but these are small in numbers. A few people ‘escape’ into other fields, often in literature or the arts.

    The question also begs the question, what is a university education for? For many, it is about stretching their academic abilities, learning about learning and demonstrating that they have a brain which is (potentially) multi-functional. (Classics students apparently make very good traders on the financial markets.)

    The government has never suggested that all law graduates should work for a ‘national legal service’, or that vets should work for a veterinary service, or architects should work for the government. These are all university subjects, but all lead, in general, to employment in that specialty. Like medicine, these are as much training specialties as they are academic specialties.

    Those who study, for example, ancient greek or latin, or English literature demonstrate that they have brains that can be used somewhere; it is an absurdity to suggest that they must work for the government for years.

    Medical students are captive; they cannot work elsewhere than the NHS for some years. That is not an argument to treat them differently from other students. It is more like force majeure.

    Liked by 1 person

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