BMJ  2008;336:990 (3 May), doi:10.1136/bmj.39555.457060.AD

Head to Head

Does it matter that medical graduates don’t get jobs as doctors? Yes

¹ Winchester, Hampshire S023 9TE

Last year’s shortfall in training places looks set to be repeated. Graham Winyard believes this is a betrayal of students’ expectations, but Alan Maynard (doi: 10.1136/bmj.39555.500613.AD) thinks it is inevitable if patients are to get the best care

Before last year, this question would have been seen as academic and irrelevant, more colloquially a complete "no brainer." As a nation we invest in medical training because we want the services of doctors, not to produce management consultants or playwrights. The thousands of young people who compete fiercely for medical school places each year do so because they want to work as doctors, not gain an expensive general education. Of course not all medical graduates pursue lifelong careers in medicine. Doctors have always made high profile contributions in other fields—Jonathan Miller and David Owen are good contemporary examples in the United Kingdom. But the cohort studies of the UK Medical Careers Research Group clearly show that more than 95% work in medicine in the long term, though not necessarily in the UK or the NHS (M Goldacre, personal communication).

Historically, the UK never trained sufficient doctors to meet the needs of the NHS. One practical consequence of this has been that UK graduates, provided they were willing to be flexible about their career choices, could be reasonably assured of being able to pursue a full medical career as a consultant or general practitioner in the UK. That this is no longer the case is the direct result of a catastrophic failure in government policy on medical immigration.¹ This has created a huge surplus of eligible applicants for specialist training. The Department of Health estimates that in 2007, 1300 UK graduates were unable to secure training places. A similar picture is expected this year and potentially for some years to come.² This is certainly now a subject for serious debate.

Staffing needs

In the late 90s it was decided to reduce the dependency of the NHS on large scale recruitment of doctors from overseas by expanding medical school places by 40%.^{3 4} There is clearly little point in investing in more doctors if they cannot train to the level necessary to make useful long term contributions to the NHS. However, attempts by the Department of Health to give priority to local graduates were confounded by the Home Office’s highly skilled immigrants programme, which gave skilled people the right to enter the UK job market.⁵

The rules of the highly skilled migrants programme have now been amended to exclude new entrants from competing for medical training posts from next year. However, this still leaves an estimated 10 000-12 000 overseas graduates who have already been accepted on to the programme in competition with local graduates. Without further remedial action, which itself is currently being vigorously contested in the House of Lords, it is projected that 700-1000 UK graduates will be displaced each year from 2009 until balance is restored.²

Senseless waste

This situation is impossible to defend on any front. It is completely incoherent in policy terms; we carefully planned and invested to achieve greater medical self reliance and thereby protect other countries, only to throw our doors open to all comers. We set out to train 2000 more young doctors each year but lost more than half of that increase last year and look set to repeat this for several years to come. Even if it could be argued that there are labour market advantages in having a glut of doctors, these would operate meaningfully only if those doctors were sufficiently senior to deliver NHS targets.

The scale and importance of this problem has attracted remarkably little comment or protest, even from medical organisations. As well as the disaster for the people concerned and the waste of both talent and public money, there are also important long term implications of breaking the link between medical training and a career in medicine. Medical students already graduate with average debts of £21 000.⁶ A 15-20% risk of having to choose between emigration and a change of career at the end of basic medical training would be a strong recruitment disincentive, particularly to graduate applicants and those with a strong caring vocation. Increased vocational emphasis risks being undermined if medical school becomes, for a substantial proportion of each intake, simply a route to a range of future employment. And it will be correspondingly difficult to secure permission for student involvement in patient care if this cannot be honestly portrayed as necessarily contributing to the training of the doctors of the future.

Most immediately and importantly, however, the present situation represents a betrayal of the legitimate expectations of those who entered UK medical training in recent years: expectations not of guaranteed jobs but of being able to pursue a career that reflected the needs of patients and the NHS. Much has been made by the BMA and others of the importance of abiding by the undertakings made to overseas doctors. It is surely just as important that we keep faith with our own medical students and graduates, whose recruitment and training has been on the explicit understanding that they are needed to work as doctors. The present situation does not just matter; it is a scandal.

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Competing interests: None declared.

References

1. Winyard G. Medical immigration: the elephant in the room. BMJ 2007;335:593-5.[Free Full Text]
2. NHS Modernising Medical Careers. Consultation on graduates from outside the European economic area. 2008. www.mmc.nhs.uk/default.aspx?page=419.
3. Medical Workforce Standing Advisory Committee. Planning the medical workforce: third report. London: DoH, 1997.
4. Department of Health. The NHS Plan. London: DoH, 2000.(Cm4818).
5. Home Office UK Border Agency. Information about the highly skilled migrant programme. www.bia.homeoffice.gov.uk/workingintheuk/hsmp/
6. Medical Students Committee. Survey of student finances. London: BMA, 2007.

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