Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Flaws in the argument
- Dylan M Wilson (2 May 2008)
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The value of doctors
- Deborah A White (3 May 2008)
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Elite ignorance
- Roland Morris (4 May 2008)
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unconvincing, inaccurate and patronising
- Jessica K Sibson (4 May 2008)
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UK needs more doctors and less bureaucracy
- John Bache (5 May 2008)
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does Alan Maynard's opinion matter any more
- christina jane spurlock (5 May 2008)
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Thinly-veiled attack on IMGs vs clear signal of things to come
- Divya Pande (5 May 2008)
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A Complex Dilemma
- Neeraj Sethi, Kaye Sarsfield (6 May 2008)
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It's an ill wind which blows nobody any good.
- Roger K.A. Allen (6 May 2008)
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I am proud to be a doctor!
- Umesh Prabhu (7 May 2008)
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Yes and no
- Andrew N Bamji (7 May 2008)
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Re: It's an ill wind which blows nobody any good.
- peter j mahaffey (7 May 2008)
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Medical workfarce planning
- David J Nicholl (7 May 2008)
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Re: Re: It's an ill wind which blows nobody any good.
- Roger K.A. Allen (8 May 2008)
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At least make it clear to applicants then
- Christopher N Gascoyne (8 May 2008)
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None
- Evan A Bayton (9 May 2008)
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Banjos and Cows
- Calum N Ross (10 May 2008)
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Political propaganda rather than objective review
- David M Howes, Birmingham, B31 2AP (10 May 2008)
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The art of medicine
- Paul E Bailey (11 May 2008)
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david howes hits nail on head
- benjamin dean (3 June 2008)
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Dylan M Wilson, Paediatric Registrar Royal Children's Hospital, Brisbane
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Professor Maynard's argument falls down on several fronts: 1) It has been proven by the MTAS debacle that workforce planning has not necessarily resulted in the best doctors getting jobs, and the worst being excluded, as suggested by Professor Maynard as being the ideal situation. If a flawed random selection process exists, it negates the ideology of "the cream rising to the top", as what has actually happened is the cream is dispersed throughout. If graduates could be confident that their abilities (or lack of) will be appropriately recognised then it might be more accepting, but the last year has shown that you could be the greatest person ever to graduate, with multiple feathers in your cap and STILL be unemployable. We are yet to be convinced a honest selection process exists. 2) I am not convinced by the ability to transfer skills learnt at medical school to other professions, particularly those outside the immediate health care profession. Is Professor Maynard suggesting that failed graduates would be able to move into the business world, are are they all destined to be drugs reps? Most professions outside of health care would be interested in an undergraduate degree related to business I would have assumed, such as an MBA. Similarly, I am not an expert in economics (because medical school didn't teach me any economics..) but I fail to see how the loss of money through training a graduate who doesn't get a job could be mitigated by their future earnings through other sectors of the economy. How does a failed medical graduate getting a job for a private business help the deficit in the Department of Health budget? Perhaps someone could explain. 3) "Medical graduates, like all other graduates, gamble when they invest in their training." This highlights a neglect of the human element of this problem. This statement fails to appreciate that the current graduates, the current undergraduates, and probably the next few years of undergraduates did not know that they were gambling by investing in medical training. For years it has been believed, rightly or wrongly that a medical degree will pretty much guarantee you a job as a doctor, and when people apply to universities at 17 years of age, this is the belief they have. To criticise these graduates and undergraduates for believing in a practice that has been in place for many years is unfair. It is not a "middle class furore" it is genuine sadness and disappointment from graduates, students, high school teachers and parents who encourage students to take this path and have then had that solid career path whipped from under their feet, and find themselves in no man's land. It would be more constructive to think about expanding medical school teaching to include subjects that would of more use in the general work force, and telling the ones still in school thinking of applying to medical school that things aren't as rosy as they are made out to be. Equally Professor Maynard should show more sympathy for those who entered medical school ten or more years ago with these idealistic views that were impressed upon them by others, and now find themselves unemployable. Finally, if in delivering the best patient care the NHS "should not guarantee the employment of medical graduates or any other group regardless of patient need..." then it is equally true that the NHS should be able to employ other groups, such as International Medical Graduates if they are better candidates and will address this patient need better. The NHS cannot fail to guarantee one group employment while simultaneously guaranteeing the UNemployment of another group. Can it? I guess only the NHS could. Competing interests: I was not shortlisted for jobs via MTAS but am better off for it by being employed in Australia |
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Deborah A White, GP StR Tees Valley Vocational Training Scheme
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I find Alan Maynard's article terrifying; his thesis seems not so much to be that it doesn't matter that medical graduates don't get jobs as doctors, but rather that health service inefficiencies and NHS funding limitations mean that we almost cannot and should not afford to employ doctors at all. He states that "...tighter NHS resource constraints may lead to nurse led primary care and reduced employment opportunities for medical graduates." This proposition appears to ignore the abilities of doctors to manage complexity and uncertainly, and the efficiencies this brings. I would suggest that ignoring the unique value of doctors is not consistent with delivering "compassionate and efficient" patient care. Competing interests: None declared |
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Roland Morris, semi retired GP Putnoe Medical Practice, Bedford MK41 9JE
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In the recent BBC Analysis programme "War on the Professions" Roy Lilley said that much of what doctors do could be undertaken by nurses, that "technology and deskilling is undermining all professions" , and "rightly so". But Sir John Tooke thought this aproach "simply naive" and that Doctors needed a "deep education to enable clinical reasoning which is absolutely key to diagnosis" and that in trials nurse substitution was not cost effective. The economist Sir Samuel Britain said Doctors "do have specialist knowlegde but they are also a trade union", and thought there was not much virtue in having licences, the public could be regarded as fully adult and be left to decide themselves as to the cost and value of a practitioner with or without qualifications; they go at their own risk, might get better tretament, might be worse. Professor Maynard takes a similar approach. Looking at the economics he thinks there are cheaper ways of doing things, that Doctors are too expensive. He writes that "tighter NHS resource constraints may lead to nurse led primary care". This ill informed biass against professionals is on parade when commenting on society as a whole. Who would Roy or Sir Samuel or Professor Maynard wish to see for advice when perplexed and unwell. DIY/internet? The Practice Nurse? or their GP? A personal perspective could rapidly alter their view. Surely this 'McDonalds medicine for the masses' approach is ignorant, hypocritical, elitist and dangerous. Yours sincerely
Competing interests: Medical parent |
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Jessica K Sibson, GPStR South Yorkshire Deanery Sheffield
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Who would disagree that ‘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’ ? We all want to work with colleagues who are safe and competent and to use a service that is staffed as such. But where is the evidence that unemployment is due to this? Presumably those responsible for training under/postgraduates are poring over it, earnestly working out where it all went wrong. No –it is the spectacular failure of the current recruitment system to differentiate between these qualities and woeful workforce planning that has led to unemployment amongst graduates. To suggest that those who failed to gain a post did so ‘due to lack of skills in making career choices and because of their inadequacy as doctors’ is misleading and insulting. And since when have medical graduates been like all other graduates? The stereotypical comparison with a law graduate falls apart when you consider the routine acceptance of shoddy practices that we have all been party to as doctors (no contract of employment, incorrect pay, late pay, bizarre code of professionalism when accepting a post – geared wholly toward the employer, consistent escalation of training costs funded personally by us combined with consistent degradation of pay and study leave allowance) the list goes on. Other graduates do not routinely accept this. This is not a moan about our conditions, but don’t patronise us with ‘all graduates get the same treatment’, we do have contact with the non medical world. The phrase ‘middle class furore’ seems wildly off the mark and totally irrelevant. Who in the middle class is upset by this? It’s newly qualified/training doctors, often with families to support who are affected. The trite description of a doctor’s role (the 'nice challenge' of combining 50 GCSE’s with good communication skills) further indicates the disparity between the authors’ view of a doctor’s role and the true picture. I agree that some competition is needed to ensure excellence and would never expect a free ride personally, nor would I like to think anyone who can get a medical degree deserves a guaranteed job. But the points used to illustrate this viewpoint are inaccurate, insulting and patronising and I am surprised the author could not make a more credible and convincing argument Competing interests: None declared |
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John Bache, Consultant in Emergency Medicine Mid Cheshire Hospitals NHS Trust, Leighton Hospital, Crewe, Cheshire, CW1 4QJ
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When did either Winyard or Maynard last visit the clinical areas of a hospital? Have neither of them realized that the UK needs many more doctors on the front line? There are simply not enough doctors to do the clinical work. But there are far, far too many managers. Yet Maynard anticipates that "their scrutiny of the variation in activity and outcomes among practitioners will intensify" and he intends to "make accurate collection of data on activity a priority". He clearly feels that even more managers will be required. Maynard is incapable of disguising his irrational dislike of doctors, even invoking the archaic class argument in anticipating "a middle class furore". Repetition of an unpalatable fact does not detract from its truth. The UK needs more doctors and far, far fewer managers, administrators and bureaucrats. The country's money is being spent in an unforgivably wasteful way, and the brightest and best of our youth are being treated abominably. John Bache Competing interests: None declared |
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christina jane spurlock, locum GP Walsall wv12 4py
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I have read Alan Maynard's criticisms of the medical profession over many years and, in the past, have tended to agree with his call for accountability, evidence based treatments, and better management, but his recent article on job security for junior doctors sent my blood pressure to dangerous heights. When the great Tony B decided to plough money into the NHS the likes of Alan Maynard had their way. Evidence, data, management, and financial accountability of the medical profession were the buzz words. The amount of money wasted on IT,GMS2 (the data collection contract that was wrongly costed by management and then blamed on 'greedy GPs'), think tanks, management consultants, third rate managers, spin doctors, and government U turns failed to show any benefit over the old system of professional commitment, goodwill and the paternalistic values of previous generations of consultants and GPs. Even private practice, previously thought to be undermining the commitment of hospital consultants was now part of the new NHS purchaser provider continuum. The workforce planners (yet to stand up and be counted) who advocated the expansion of medical schools with the simultaneous influx of overseas doctors were either incompetent, naive, or totally cynical (a large influx of overseas doctors and over production of new graduates was a sure way of negating any voice that the doctors had) and the inadequacy of the online application system was unbelievable. These were all management decisions with input from the likes of Alan Maynard. Having demonstrated how people who have voiced opinions over the years with no practical experience of frontline medicine, can mess things up on a monumental scale, at least have the grace to apologise to the demoralised young doctors who are holding the fort. Thanks to the inate professionalism and feeling of duty to patients that is bred into young doctors the NHS functions against all the odds. Only a doctor who has survived the stress and unsocial hours will understand this (believe me nurses are no substitute for an SHO, GP or even a prereg. HO). To blame them for being unrealistic in their expectation of a job at the end of years training, unpaid overtime, and unsocial hours, leaves me !!!!!. Competing interests: ex Gp principal, mother of four junior doctors, 2 clobbered by the MTAS debacle |
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Divya Pande, GP locum West Midlands
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Both these authors do no credit to the BMJ. Graham Winyard's article is nothing more than a disgraceful piece of spin which encourages the discimination that our overseas-trained colleagues face daily to continue. Those in senior positions will be reassured that they are contributing to safeguarding the prospects of UK graduates by maintaining the status quo in using discriminatory selection procedures for training posts. Alan Maynard's article on the other hand contains blatant untruths in just about every paragraph, most of which have been discussed in the other rapid responses. He has managed to make sweeping generalisations about almost everybody involved in the delivery of healthcare in the UK, quite a feat for a single page of the BMJ. "Does it matter that medical graduates don't get jobs as doctors?": these words appearing on the front cover of the BMJ have truly captured the zeitgeist, but perhaps 'don't should be replaced by 'can't'. Competing interests: None declared |
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Neeraj Sethi, ST2 ENT York Hospital, Kaye Sarsfield
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Though there is nothing like a black and white answer to stir controversy we feel this is not so easily broken down. Professor Maynard's analogy of law is an unfair one. Law students do not enter their degree knowing that they are being prepared for the majority of their working life to be part of a state service - only minority of law students would enter this arena. Every medical student in the UK is being prepared for work as a National Health Service soldier; indeed Alan Milburn's letter in 2001 welcoming all medical students in the UK demonstrated the state's interest in their NHS career. The NHS is not their only option but it certainly looms large in everyone's image of what training to be a doctor in the UK means. In an NHS that made a surplus (it is not technically profit) of £510m in 2006- 7 blaming doctors as an inefficient method of delivering health care is certainly in vogue. One cannot deny that nurses are cheaper to pay than doctors and as such will be pushed forward to replace medical roles at any opportunity. Clinical governance will show whether this has truly improved care or not despite cost-efficiency studies. Suggesting that world-wide authorities see reducing doctors as the way to save money is misleading and inaccurate. We would heartily encourage competition at all levels for doctors to ensure standards are not simply maintained but pushed higher. This means that at every career stage unemployment in a particular specialty or within the field altogether is a possibility. However to ensure that medical graduates are continually selected at the highest levels it must appear an attractive and viable career opportunity - not one that is unattainable or likely to be dead end. Conspiracy theorists would accuse the government of striving for medical unemployment as desirable in order to secure more leverage over contractual negotiations with medical groups. Finally we believe that the NHS priority is to patient need, whether this is physical, social or emotional. It is an egregious statement indeed that only compassion and efficiency are needed. The finite restraints of the NHS must always focus on what is best for the patient. Whether it is more doctors or expensive treatments the point is not to guarantee employment but not to lose sight of the patient in the ceaseless efforts to pinch pennies. Competing interests: Both authors obtained run through training posts last year |
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Roger K.A. Allen, Senior Consultant Thoracic and Sleep Physician Wesley Medical Centre, Auchenflower, Brisbane, Australia
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In 1788, the British government sent an impressive fleet of convicts and marines to some vacant real estate in Botany Bay and ever since they have obliged us with a steady influx of British doctors rather than keeping them imprisoned in rotting hulks along the Thames estuary. The then New South Wales, now called Terra Australis or for the aborigines, Terra Nullius, has currently a mere 20 million convict descendants, a few free men and the odd survivor of the aboriginal holocaust, and all living on a large plot of 3 million square miles of dirt. It has more near- extinct koalas than doctors, and as result I can assure nervous British graduates facing penury and debtors' prison, to move from the what was formerly known as Great Britain, to the land of the endless barbee (BBQ) and long weekend. We are crying out for doctors and nurses. Even the current PM's (Mr Rudd also known as Kevin or Kev) electorate in Brisbane is desperately short of GP's. Patients from the country think nothing of driving five hundred miles one way to see a specialist. Many country towns have no GP. Pregnant women have to travel hundreds of miles to see an obstetrician. This mess is all the legacy of numerous governments of both sides of the fence as well as numerous medical committes and "think-tanks" stuffing up their predictions of future health needs about twenty years ago. We have both an aging and growing population, more women doctors working part-time, doctors leaving medicine prematurely, and strangely, no longer willing to work one hundred hours week. Incentives to work 24/7 in the country and be the only doctor in ten thousand square miles has put the dampener on our own docs flocking to the country like a mob of gallahs (parrots and also a pejorative) to a ten thousand acre paddock of ripe sorghum. High-achieving students are leaving school now to enter more lucrative training for jobs such as business, real estate, stock market and even law as we have caught the American disease. I have personally advised several such excellent students to steer well clear of medicine unless they have a need for self-flagellation, a divorce, the taking on of holy orders or the vow of poverty also known as medical research. Australia has increased its medical school intake but it will be years before we are exporting doctors back from the colonies. So as they said to lure our sons to fight in trenches of the Great War, "Cooey, come over, boys". Competing interests: None declared |
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Umesh Prabhu, Consultant Paediatrician The Pennine Acute Hospitals NHS Trust
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Over the years I have read many of Prof Maynard's articles and criticism of doctors and indeed did agree with some of his suggestions that NHS must be good value for money, waiting time reduction and perverse incentives in the NHS. However, in this article I think even he has gone too far. Comparing medical profession to the lawyers is not just an insult but he is comparing apple with pears or shall we say diamond with coal! Medical profession is even today well respected and trusted profession and lawyers still have a long way to go to earn that trust! Lawyers do not work in the state run monopoly employer like NHS. They can work in any industry, any Institutions and any walk of life because of so many confusing legislations. Lawyers can open a high street office without any regulation or a sort of hotchpotch regulation. Lawyers do not train for nearly 10 years to become consultants and lawyers definitely do not work day and night and unsocial shift systems which most doctors do. To say that most doctors don't get jobs because they are incompetent is nothing but rubbing salt to the wound. Of course quality of clinical care, patient safety and their well being must be at the heart of our NHS and any incompetent doctors must be removed like any incompetent Chairman of the Trust. My only concern is because of Prof Maynard's position as the Chair of York Foundation Trust. I sincerely hope we won't see York Hospital full of nurse consultants or consultants imported from Spain (Salary scale is very low in Spain and EU regulation does allow them to come and work in the UK) and many unemployed UK doctors walking on the streets of York. What we need is a proper long term medical workforce planning, excellent training for these doctors and effective performance management with quality assurance systems in place where patient safety and their well being is at the top of our NHS agenda and doctors and nurses working as a team and providing good quality care to our patients. NHS should be run by clinicians and not by bureaucrats. But it is equally important for the medical profession to show true leadership and make sure that our patients get the best value for money and the best possible care. Competing interests: None declared |
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Andrew N Bamji, Consultant rheumatologist Queen Mary's Hospital, Sidcup, Kent DA14 6LT
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Winyard and Maynard are both right in parts. It seems crazy to train people for jobs that aren't there. But a selection process does pull out the best qualified (although with the MTAS system it was hard to do this) and that can only be good. However it is the scale of medical unemployment (estimated to be the equivalent of the annual output of three medical schools) that is staggering, and unacceptable. If our borders are open to all EC comers - and across the Channel there is oversupply also - the problem compounds. However an increase in the UK medical workforce would solve the problems of the European Working Time Directive and make redundant all discussions about hospital mergers to allow safe rotas. So if we are training too many doctors for the existing jobs, increasing the job pool solves another problem. At a cost. Competing interests: Works in an acute Trust under threat of reconfiguration |
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peter j mahaffey, consultant surgeon bedford hospital mk42 9dj
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Nice one Roger! There's a rather satisfying poetic justice in seeing the UK (seemingly unaware of what's happening) paying for the education of doctors who are migrating in their hundreds to Australia after the NHS has spent years raping the third world, particularly Africa and the Phillipines, of its nurses. Competing interests: None declared |
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David J Nicholl, Consultant Neurologist Department of Neurology, City Hospital, Birmingham B18 7QH
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The ongoing saga of MMC truly beggars belief when one reads the response of Prof Alan Maynard. The expansion of workforce numbers by the Blair government is more than "over-ambitious", it has been scandalous and the waste of tax-payers money on training too many doctors and opening medical schools that are not needed, outrageous. Unfortunately the scandal continues as evidenced by a written Parliamentary answer from the Home Office earlier this year. Since the MTAS debacle no less than 2,095 Highly Skilled Programme Visas have been issued(1) and neither the Home Office nor the Department of Health keep any record of what speciality of doctor the HSMP holder is. Clearly this country needs to have a facility for migration of highly skilled professionals to enable the health service to function. However when the government seems to still have no ability to even collect the most basic of data, one has to question their competence to do any form of medical workforce planning. Reference 1. http://www.theyworkforyou.com/wrans/?id=2008-01-28d.181167.h Competing interests: I am chair of the Regional Training Committee in Neurology |
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Roger K.A. Allen, Senior Consultant Thoracic and Sleep Physician Wesley Medical Centre, Auchenflower, Brisbane, Australia
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It is sheer folly that successive Australian governments and medical colleges did not train enough graduates, fixing the numbers at 2000/annum and that we "suck" doctors and nurses from underdeveloped countries. It was cheaper just to draw on overseas graduates than invest in infrastructure. The medical colleges were seen as colluding in the restriction of graduate numbers as a way of maintaining a monopoly and therefore controlling fees. This is open to quesion. For good training standards, you need teachers and hospital jobs. This is not a sausage factory. At present medical schools here are at increased capacity and hard-pressed to find medical teachers and are now using private hospitals and specialists as well. On the other hand, if doctors from such "poor" countries were so altruistic, they would return to their own countries to work, even on low salaries. Blame cannot just be levelled at the more affluent countries for the brain drain. The same now applies to airline pilots in the USA who are leaving to work overseas for better pay and conditions. Perhaps all this says is that we live in a global economy which allows for free market forces not only in bananas and copper but also in labour, including bodies with stethoscopes in their ears. We will go where the wind blows viz the First Fleet in 1788 which sailed east to Oz because of a convict surplus back home following the Boston Tea Party. One country's surplus production of graduates is a boon to some other country or in other words, one man's meat is another's poison. Competing interests: None declared |
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Christopher N Gascoyne, Medical Student Peninsula Medical School
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When I applied to medicine, a good 5 years ago, the message was that the UK needed doctors and that there were more jobs than graduates. I had this as good as spelled out to me at one of the Medlink conferences I attended whilst in the 6th form. I applied, quite rationally I think, under the assumption that as a medical graduate it would be relatively easy to get onto a medical career. As far as garunteeing quality goes I also though it would be a fair assumption that if I was incapable as a clinician I would be prevented by the system. If the side we are going to pick as a nation is that it doesnt matter, then could we please ensure that it is made explicitely clear to potential undergraduates that they will be facing these issues upon graduation, and with a sizeable debt under many of them as well. I suspect that you will find applications falling; Knowing what I now know, I would certainly reconsidder if I was back at that time now. Competing interests: None declared |
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Evan A Bayton, Emergency Medicine Consultant Burnley General Hospital BB10 2PQ
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Once again Alan Maynard expresses his barely disguised contempt for the medical profession which as others have noted is irrational and does not sit well with his reflections on health economics. In fact if you substitute the word "economist" for "doctor" the article reads just as well and makes more sense. I am reminded of the old Manchester University joke about the Economics student who went to the library to look up past finals papers and found that they were the same every year. When he went to see the professor he was told that it was easy to explain why. "We just change the answers every year". Maynard makes the usual academic's criticism of medicine being like fifty GCSEs which is a subtle way of implying that Medicine is not really an academic discipline and medics should not really be considered worthy of academic consideration. However Medicine was a University course before Economists were invented and Medicine in some form will continue long after Maynard and his bitter crackpot ideas have been forgotten rather like so much dusty Victorian Theology is today. Competing interests: I am a registered medical practitioner with a licence to practice whose income depends on my job as an A&E consultant |
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Calum N Ross, Consultant Physician NNUHT, NR4 7UY
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It must have been hard to find someone under the age of 50 and without a secure pension to support the ‘No’ position. The most charitable explanation for Alan Maynard’s contribution is that he was doing his best to lose the debate. Three arguments – political, economic and quality – could be used to justify medical unemployment but Alan Maynard completely misses his brief. Banjos and cows’ arses come to mind. His main argument is political. He sets out – as a DoH employee should dutifully do - the Government’s stall but makes no practical connection between the end and the means. In summary, he promulgates the Government policy of training an excess of doctors in order to favour buyers over sellers. He adds to this the training of nurses and technicians to take on single-skill procedures to disenfranchise the medical profession even further. The thinking seems to be that a large, cowed, unemployed medical work-force will be easier to deal with than the current small, cowed, employed medical work-force. Successive governments have been tamed by a, never-very realistic, threat of industrial action. But not for much longer – we’ve just decommissioned our most powerful weapon, exclusivity (and got nothing in return). And we only have ourselves to blame. Deans of Medical Schools are packing two students to a chair and whilst consultants train technicians in procedures, the disenfranchised unit SpR is teaching 12 more turkeys on topics they are never likely to get a chance to practice, this or any other Christmas. Alan Maynard is unable to muster any cogent argument that medical unemployment will improve the quality of medical care. 50% of doctors are below average. Hitherto, this has been 50% of a pretty ambitious, intelligent, able and motivated (but not necessarily pretty) medical profession. If you accept that medical training posts have been appointed competitively, doubling the medical workforce (and bear in mind, some of the expansion of medical training has included post-graduates from undemanding degree courses) must reduce the calibre. If you then add to this mix non-medical practitioners, there must be an overall reduction in the intellect, training and expertise in the health service. And if you add to this mix a demoralised, indebted and unemployed medical work-force, the calibre of applicants to medical school must trickle down a spiral of declining averageness. How could this possibly maintain let alone improve standards? Alan Maynard mangles the economic and quality arguments. He tries to re-define improved care as an economic issue. Quite why he thinks £250K for an unemployable medical graduate is financial prudence and not fiscal profligacy escapes me, and, clearly, him. And quite why he thinks this expenditure is going to improve the outcome of, say, his hip replacement is an argument he has yet to make. Medical training used to be prestigious and aspirational and professional and, if we want the brightest and best to look after our ailments, we better make certain it is again. Consultants (and especially educationalists) have been complicit in this process and we should redeem ourselves by insisting on proper work-force planning. It is actually possible to square the circle of improved economy and maintaining medical expertise without resorting to the, rather nasty and destructive doctors-are-the-same-as-everyone-else-and-deserve-to-be-unemployed argument. The rules of engagement would include two absolute and two relative rules: 1) Work-force planning must identify doctors’ roles and ‘service-provider’ roles. I entirely accept that single-skill, non-doctor practitioners, for example, in anaesthetics or endoscopy, are likely to be an increasingly important, and economical, part of the work-force. But they shouldn’t be in competition with a doctor with different and extended skills and it is not a policy that is improved by medical unemployment. 2) The number of medical school places must reflect projected doctors’ work-force requirements. If we need fewer doctors then we must train fewer doctors. 3)The number of medical school places should include a negotiable percentage increase to allow for wastage. 4) The number of places should include a negotiable percentage decrease (if equal, these two allowances obviously cancel out) for overseas graduates. Yours sincerely, Calum Ross Competing interests: None declared |
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David M Howes, Consultant Anaesthetist Royal Orthopaedic Hospital, Birmingham, B31 2AP
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After reading Professor Alan Maynard’s answer “No” to the question “Does it matter that medical graduates don’t get jobs”. I undertook a quick internet search that confirmed my impression that he had never been through any medical training. However his attitude to doctors and their training, and the overt political views that he expresses need a response. I would be interested in the Medical Schools response to the view that training is no more than “studying for 50 GCSE’s” and it is a “nice challenge” to apply “these skills in a caring, humane and efficient manner” The overproduction of medical students is not an accident unless the health economists are more incompetent than we already think them to be. Employment of British graduates is threatened from 2 sources, other than overproduction. The first is the importing of doctors from abroad (a subject Professor Maynard, perhaps wisely, does not address) This has always occurred to cover shortfalls in medical school numbers, but now we have the opening up of the market from the European Union and the “highly skilled migrants” programme. These are economic migrants who come here primarily for financial reasons and although they will have a degree and some experience we cannot really tell the “practice style” they will have learnt. Although I would suggest it will be less acceptable than that of the British graduates who have a vocational reason for working in this country, not a financial one! The reason why the legal profession/ government has allowed this to happen could be the subject of an article in itself. (I believe the two are too close and there are “conflicts of interest”) The second is that non-medical staff, especially nurses, could take over functions at present undertaken by doctors. Professor Maynard threatens that they could give anaesthetics, do minor surgery and take some of the functions of GP’s. While they are excellent complimentary practitioners, the medico-legal environment we find ourselves in means they will have to be closely supervised (by doctors) to avoid even minor morbidity. The real aim (because I do not believe this situation has come about by accident) is to produce the insecurity of unemployment in home grown graduates, knowing those from abroad and non-medical graduates will just be glad to have the job. The political intention is to take away the power of the doctors so they can be more easily controlled. The Governments main priority in NHS policy is to minimise politically embarrassing stories. This has been so consistently since the mid-1980’s and has driven the increasingly frantic health service reforms. This is more important than limiting expenditure, as is shown by the lack of concern in money wasted in IT disasters, PFI projects and medical students for whom there are no jobs. A theme in Professor Maynard’s piece is cost effectiveness and “variations in medical practice” are blamed for this. There will always be variations in care, and debate about the best way of managing problems, but the great majority of NHS treatments have not strayed far from the mean. He should perhaps look critically at initiatives such as the Independent Sector Treatment Centres (ISTC’s), where patients were cherry- picked to avoid high risk cases, but despite this morbidity and mortality was significantly higher than for NHS patients. However like many facts this is suppressed by the control freakery now evident in the NHS. The tone of Professor Maynard’s piece betrays his allegiance is not neutral and confirms this as effectively a Government view. It is just a pity that committed doctors will be victims of this policy. Competing interests: A child as a junior doctor |
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Paul E Bailey, Praticien Hospitalier Centre Hospitalier F-68250 Rouffach
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Dear Prof Maynard, As an economist, you must be very upset that "Delivery of health care is highly inefficient" and that "Much of medical practice lacks an evidence base of clinical let alone cost effectiveness". However, cost effectiveness studies require exact knowledge of the monetary costs of death and suffering, and I know of no objective way of determining them. So I prefer to treat my patients using a mixture of scientific knowledge, reported in studies which do not reflect the everyday clinical world, and common sense. I was most surprised to learn that I "gambled" when I "invested in my training". Gambling, being the acquisition of money without work or talent, is surely the greatest of all sins, and I do not believe I have ever indulged in it. Since you know the price of everything and the value of nothing, perhaps you would tell us the exact cost of the suffering experienced by a medical graduate who cannot find a job. I'll allow you an error of 50 cents (or pence) in either direction. Yours sincerely Paul Bailey Competing interests: None declared |
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benjamin dean, sho oxford
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A fact that Professor Maynard and his kind fail to appreciate is that nurses are trained for nursing and doctors are trained for doctoring, and that the two are rather different things. The naive policy makers seem to think that all NHS workers are all Health Care Practitioners of a kind, and one can be seemlessly blended into another with cheap short cuts. Professor Maynard should know that it is often true that you only get what you pay for, so employing the less skilled to do jobs that were done by more highly skilled and highly trained workers reduces the quality of the service. In the world of health care the reduction of quality can cost lives. Finally Professor Maynard hint that the cut throat competition between providers in a Darwinian manner will lead to service improvements, unfortunately this view betrays a tremendous lack of understanding of biology and economics. Improvements in service would be best achieved by creating a competitive environment which encouraged efficient cooperation between providers. This is very different to creating a competitive environment in which everyone is working against everyone else while the objective of health care (caring for patients) is forgotten, in reality this is what the current incomepetent regime has created. So instead of productive cooperation, we have the internal market which consists of multiple layers of needless bureaucracy that end up working against the interests of patients in a thoroughly uncooperative manner. This is the legacy of the Professor Maynard's flawed ideology, an inefficient bureaucratic nightmare in which everyone has forgotten what a health system is meant to do. Competing interests: None declared |
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