Editorials

Planning the United Kingdom's medical workforce

On present assumptions UK medical school intake needs to increase 

Without an appropriate workforce, health service delivery will fail. The function of medical workforce planning is to ensure, so far as possible, that the right numbers of doctors, in the right specialties and grades, are in the right places. Traditionally national policy in the United Kingdom has been to provide an adequate supply of doctors while avoiding overproduction and unemployment. The policy has also been to train enough doctors for self sufficiency without reliance on net immigration. The main mechanisms for achieving these policies have been through fixing quotas for the number of places in medical schools and through a variety of mechanisms to control the number of NHS medical posts in each grade, specialty, and location.

Several factors tend to increase the demand for health care and for doctors. Population size and structure, notably its ageing, is reasonably straightforward to estimate. Advances in medical knowledge and technology are less predictable. They increase the scope for treatment and increase specialisation, which, in turn, tends to increase the range and number of specialists. Hitherto, technological advances in medicine have generally increased, rather than reduced, costs and the need for medical staff. Public expectations to meet needs and improve quality of care, fuelled by professional aspirations, media interest, and political promises, will continue to rise. Large waiting lists and long waiting times persist. Reductions in bed numbers, shortening lengths of hospital stay, and increases in throughput enhance the efficiency with which capital stock is used but require an intense pace of medical work. Shorter working hours for junior doctors, European legislation on working time, and consequential increases in pressures on consultants' time also all compellingly suggest expansion of the medical workforce. Expansion will be needed, too, because of the increasing proportion of women in medicine and because of needs for part time and flexible working.

As well as these general trends, the Calman reforms of postgraduate medical training and recent white papers on the NHS create a further set of requirements. The former will lead to an increase in the proportion of care which is provided by consultants, but more time will be needed for training in a shorter training period, from both the junior doctors being trained and the senior doctors who train them.¹ Patient care will gain, but medical time will be needed, to implement the measures in the white papers to assure effectiveness and improve quality² and to increase involvement in audit, continuing medical education, and professional development. The changes in management arrangements, in particular involvement of general practitioners in commissioning through primary care groups, will consume doctors' time. Reductions in time spent on direct patient care will increase the need for more doctors.

Are there any countervailing pressures that might work against the apparent need to increase the number of medical students the UK trains? Improvements in the health of the population to the point where medical needs actually reduce sound plausible but there is no evidence of this happening. One possibility is the transference of tasks from doctors to non-medical staff. Another is to reduce wastage of medical students through medical school and of trained doctors after qualification.

Decisions on the number of medical students needed to produce tomorrow's doctors are bedevilled by the long lead time between entry to medical school and attainment of specialist qualifications, the impossibility of forecasting the shape of clinical services many years ahead, and uncertainty about the career pathways doctors will take after qualification. The Medical Workforce Standing Advisory Committee advises the Secretary of State for Health on planning the medical workforce. In its third report, published late last year, which covers evidence on the issues described above, the committee recommends an increase in UK medical school intake of about 1000 a year (a 20% increase ) to meet increasing demands and reduce reliance on overseas trained doctors.³ The government's response is expected shortly. The report observes that the percentage of doctors in the United Kingdom who were trained overseas has increased, comments that the gap between demand and home supply will grow further unless measures are taken to avoid this, and continues to favour self sufficiency in training the doctors we need

The report also discusses the need to minimise wastage of students in training and doctors after qualification. It worked on the assumption of a loss of 10% of students from medicine during medical school.³ The true figure may be a little higher,⁴ or a little lower,⁵ and we need more precise information. A case also exists for implementing routine "exit interviews" with medical students who change course or quit higher education to determine why we lose them. In the first 10 years or so after qualification a further 15-20% of doctors are lost to the NHS.⁶ These comprise, in particular, doctors who practice abroad and married women doctors who, often temporarily, are not in paid employment for domestic reasons. The possible impact of an increase in early retirement is another important supply factor. Intentions and plans for early retirement need more study than they have received.

Are there alternatives to expanding medical student intake? In a recent paper Maynard and Walker argue that more consideration should be given to the role of financial incentives, and other incentives relating to conditions of service (such as part time contracts), in retaining doctors in the workforce, reducing emigration, and reducing the wish to retire early.⁷ They also challenge the principle of national self sufficiency, pointing to the free movement of labour within the European Union and the fact that several European countries produce substantially more doctors than they employ. Few would favour reliance on poaching doctors trained in or for the developing world. But for the United Kingdom in Europe there is a question to answer. In future should the aim be for UK or European self sufficiency? On the present assumption that we should not depend on doctors trained overseas, and given profound changes in doctors' hours and work patterns, the workforce committee is right to conclude that a substantial increase in the annual medical student intake runs no serious risk that the United Kingdom would train too many doctors.