Published 3 June 2009, doi:10.1136/bmj.b2223
Cite this as: BMJ 2009;338:b2223

Editorials

The future of female doctors

Women will have to adapt as they become the majority, and so will the NHS

Women will form the majority of doctors in the NHS within 10 years. The suggestion by Professor Carol Black that the future of British medicine might be endangered by this feminisation of the medical workforce generated both media hyperbole and serious debate.^{1 2} By raising these issues directly, Prof Black crystallised a range of professional concerns and made it legitimate to discuss fears and perspectives that might otherwise have been dismissed as politically incorrect, or worse.

Women and medicine: the future, the reports published this week by the Royal College of Physicians, tackle these issues head on. The summary report³ is based on a major and meticulously referenced study⁴ by Dr Mary Ann Elston that provides a sturdy foundation for the future work that is recommended. Most readers will opt to read the shorter version, but the full report contains fascinating new perspectives from other professions and other countries.

The report easily puts to rest some false but widely held beliefs. Projections that women will constitute 70% of medical school entrants are not being fulfilled; the proportion seems to be stabilising at around 57-58%. Neither are men disappearing from medical schools; in fact, 50% more male medical students were admitted in 2007 than 10 years earlier. The steep rises in the numbers of both sexes make future shortages of specialty doctors, or a lack of medical leaders, most unlikely. In addition, no evidence exists that women are more likely than men to leave medicine entirely. Overall, the Royal College of Physicians report should perhaps make more of the success implicit in its statement that "the main challenge ahead is no longer barriers to entry or delays to the career progression of women . . ." Its comparisons with solicitors, dentists, vets, and pharmacists certainly suggest a less favourable situation in other professions.

The linked questionnaire study by Taylor and colleagues (doi:10.1136/bmj.b1735) confirms that there is no evidence that female NHS doctors have been directly disadvantaged in their career progression, or that having children negatively affects the career progression of women who have always worked full time.⁵

The Royal College of Physicians report sees the new challenge as being "to ensure that the increasing proportion of women is effectively, economically, and fairly incorporated into the workforce for the benefit of patients." Their start point is an analysis of women’s specialty choices and preferred modes of working. Specialties are categorised on the basis of their relative orientation to technology or to people and on the unpredictability of workload. Women tend to favour people orientated specialties with more plannable workloads. This pattern, which is replicated in other western countries, is explored in the report, and clearly links to the wish of many women to work flexibly and the need for career breaks, not least to have children. Cohort studies 15 years after graduation suggest that women doctors on average provide 75% of the service contribution of men.

The potential impact of these workforce issues on patient care and the NHS is the focus of the report’s key recommendations. The Royal College of Physicians recommends that the organisational implications of changing workforce patterns and preferences with respect to working hours and specialty choices should be examined, and their economic effect evaluated. They highlight the need for better workforce information to support this work, as well as strengthened workforce planning and modelling, which in turn should inform the career choices of young doctors.

The common sense of all this seems incontestable, but there are two serious problems. The first is that the preferences of female doctors, which the report articulates well, have to be matched with employment opportunities. The labour market for doctors looks set to become much harsher, with NHS funding strait jacketed by the worst public sector finances since the war and substantially more UK trained doctors are seeking employment as a result of recent expansion of the country’s medical schools.^{6 7} In the current devolved NHS, decisions on the organisation of services and the employment of doctors will be taken by independent foundation trusts, and preferred options for specialty or work/life/family balance may simply not be available.

The second more prosaic problem is our poor collective track record in bringing these sorts of strategic discussions to any useful conclusion. As the report itself highlights, consideration of patterns of medical work lead immediately to questions of tiered consultant grades and the role of non-specialist career doctors, the stuff of central policy gridlock for decades.

But the problems the report highlights are difficult to tackle and will not go away, and they are better tackled nationally in a coherent way rather than piecemeal locally. NHS Employers could make a start in partnership with Medical Education England or the Academy of Medical Royal Colleges. Once established, Lord Darzi’s Centre for Workforce Excellence is an obvious organisation to support the associated thinking and analysis.⁸ Further work must have employers at the heart if proposals are to have a practical impact. Success will depend on their recognising the legitimate needs of their evolving medical workforce, and on doctors individually and collectively taking realistic and evidence based views of their careers.

Cite this as: BMJ 2009;338:b2223

¹ Winchester, Hampshire SO23 9TE

10.1136/bmj.b1735

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Laurance J. The medical timebomb: "too many women doctors." The , Independent, 2 August 2004. http://www.independent.co.uk/life-style/health-and-families/health-news/the-medical-timebomb-too-many-women-doctors-551149.html.
2. "Women weakening medical profession." The Daily Telegraph, 3 August 2004. http://www.telegraph.co.uk/news/1468464/Women-weakening-medical-profession.html.
3. Women and Medicine: the future. Summary of findings from Royal College of Physicians research. London: Royal College of Physicians, 2009.
4. Elston MA. Women and medicine: the future. London: Royal College of Physicians, 2009.
5. Taylor KS, Lambert TW, Goldacre MJ. Career progression and destinations, comparing men and women in the NHS: postal questionnaire surveys. BMJ 2009;338:b1735.[Abstract/Free Full Text]
6. Hubris and nemesis. The Economist, 23 April 2009. http://www.economist.com/displaystory.cfm?story_id=13528003.
7. Pounder R. The medical production line in England. College Commentary, October 2007. http://www.rcplondon.ac.uk/news/eu/CC_07_03Oct_Med_Prod_Line.pdf.
8. Department of Health. High quality care for all: NHS Next Stage Review final report. 30 June 2008. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825 (Search for: 10106).

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