BMJ  2008;336:991 (3 May), doi:10.1136/bmj.39555.500613.AD

Head to Head

Does it matter that medical graduates don’t get jobs as doctors? No

¹ Department of Health Sciences, University of York, York YO10 5DD

Last year’s shortfall in training places looks set to be repeated. Graham Winyard (doi: 10.1136/bmj.39555.457060.AD) believes this is a betrayal of students’ expectations, but Alan Maynard thinks it is inevitable if patients are to get the best care

The government, as the main employer of doctors in the United Kingdom, is responsible for planning the medical workforce proficiently in order to deliver patient care. This requires it to model demographic trends, specialty needs, skill mix, technological change, and resource consequences. However, its manifest failure to plan efficiently does not create the responsibility or need to guarantee medical graduates employment.

Doctors cost hundreds of thousands of pounds to train. This training gives them specific skills as well as transferable skills. The training expenditure is a sunk cost—that is, once spent it cannot be retrieved. If medical graduates are unemployed this loss can be mitigated by their finding employment in other sectors of the economy, just as graduate lawyers do if they are unable to find jobs after academic and practical training.

Medical graduates, like all other graduates, gamble when they invest in their training. Their success brings riches, but if they fail due to lack of skills in making career choices and because of their inadequacy as doctors, they are no more eligible than other graduates for compensation in terms of job guarantees.

Practitioners in any field should be given jobs only if they have appropriate knowledge, skills, and personal behaviours consistent with meeting their employers’ and customers’ needs. Medical school training can be likened to studying 50 GCSEs, requiring a breadth of knowledge but needing little application of the great intellectual proficiency of the academic elite that is recruited to medicine. The nice challenge for students is the application of these skills in a caring, humane, and efficient manner.

Guarantees are incompatible with efficiency

Delivery of health care is highly inefficient. Much of medical practice lacks an evidence base of clinical let alone cost effectiveness.¹ Variations in medical practice are ubiquitous and have been researched for decades and ignored.² "Practice style" learnt in medical schools from peers and drug marketers, leads to patients with similar needs and characteristics getting very different packages of treatment, while at the same time proved therapies are not delivered to patients.

Thus in the US Medicare system potential savings of 30% of the budget have been identified² and it is estimated that Americans get only 55% of the health care they need.³ Similar depressing findings were publicised by the then Secretary of State for Health, Barbara Castle, in 1976,⁴ and are now "core business" for the NHS Institute for Innovation and Improvement.⁵ Improving this situation may mean a complete rethink of the way we deliver health care.

The tardy recognition of the inefficiency of health care delivery worldwide means that the market for medical graduates in the future is uncertain. This uncertainty is reinforced by changes in skill mix. For instance, the Blair government in a direct challenge to the monopoly power of medicine began the licensing of nurses and pharmacists as prescribers. The emergence of nurse endoscopists, nurse anaesthetists, and the training of nurses to carry out minor surgery have the potential to reduce the demand for medical graduates.

Primary care has also seen an increase in the employment of nurse practitioners and nurse prescribers. It is unclear whether these investments are substitutes or complements to general practitioners, but tighter NHS resource constraints may lead to nurse led primary care and reduced employment opportunities for medical graduates.

Survival of the fittest

As hospital managers move from their current emphasis on tactics to hit government targets to the recognition that their survival depends on strategic quantitative management of the medical workforce, their scrutiny of the variation in activity and outcomes among practitioners will intensify. The government now publishes comparative data on the work levels of all consultants.⁶ Hospital tariffs (payment by results) make accurate collection of data on activity a priority to ensure funding. This together with investments in cost and outcome data at the level of the practitioner will make clinical performance in hospitals more transparent. Employers will seek to identify outliers and be more rigorous in recruitment and retention practices.

The thrust of Labour and Conservative NHS policy is local flexibility and the decentralisation of job markets. The success of the recent contractual negotiations in increasing payment and making medical graduates expensive to employ means that employers will increasingly look for economy and changed skill mix. The European Union working time directive together with the feminisation of the workforce with medical graduates whose activity rates may be lower than those of their male peers, ⁷ may palliate the threat of unemployment.

However, the over ambitious expansion of medical workforce numbers by the Blair government will inevitably lead to some unemployment, raising an inevitable middle class furore which has to be resisted. The purpose of the NHS is to deliver patient care that is compassionate and efficient. It should not guarantee the employment of medical graduates or any other group regardless of patient need, personal skills, and the finite resource constraints of the NHS.

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Competing interests: AM is chair of York Hospitals NHS Foundation Trust and has received grant funding from the Department of Health and other bodies to research workforce issues over the past 25 years.

References

1. BMJ. Clinical evidence handbook. London: BMJ Publishing, 2007.
2. Fisher ES. Medical care—is more always better? N Engl J Med 2003;349:1665-7.[Free Full Text]
3. McGlynn ES, Asch J, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the USA. N Engl J Med 2003;348:2635-45.[Abstract/Free Full Text]
4. Department of Health and Social Security. Priorities in health and personal social services. London: HMSO, 1976.
5. NHS Institute for Innovation and Improvement. Delivering quality and value: focus on productivity and efficiency. London: Department of Health, 2006.
6. Bloor K, Maynard A. Consultants: managing them means measuring them. Health Serv J 2002;112:10-1.[Medline]
7. Bloor K, Freemantle N, Maynard A. Gender and variation in activity rates of hospital consultants. J R Soc Med 2008;101:27-33.[Abstract/Free Full Text]

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