Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: UK trained doctors, “part time” working, and ongoing commitment to the NHS

BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2794 (Published 17 November 2021) Cite this as: BMJ 2021;375:n2794
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}googlemail.com
    Follow David on Twitter @mancunianmedic

Over the past few months, in response to stories about GP shortages, I’ve seen many opinion columns and letters arguing that too many UK trained doctors are working less than full time (LTFT) or are leaving the NHS for alternative employment. Some of the writers propose that if doctors aren’t prepared to work a certain number of years for the NHS, and full time at that, they should repay the cost of their “£250 000 taxpayer funded training.”12

In essence, they argue, we could solve the NHS’s medical workforce crisis by forcing people to work full time, tying them into NHS working for a fixed number of years, or even cutting pay or pensions so that they have little choice. Sadly, I’ve also seen many remarks that too many women are becoming doctors and that motherhood will make them part time workers—something that The BMJ’s columnist Helen Salisbury wrote about last week.3

For me, these viewpoints range from ill informed to ill conceived to ill willed, outrageous, and discriminatory. I know that a proportion of NHS doctors work LTFT or spend only a proportion of their time on clinical work and directly related admin. In medical disciplines such as general practice, where we’ve seen a fall in full time equivalent numbers, one contributory cause is a higher proportion of fully qualified practitioners working LTFT, even though (as with general practice) absolute numbers of doctors have also fallen.45

Four in five salaried GPs now work LTFT, and only one in 20 GP trainees told a King’s Fund survey that they intended to work full time.6 The 2018 workforce census of the Royal College of Physicians showed that 23% of consultants worked LTFT,7 with a range of 9-55% depending on specialty: 41% of female consultant physicians were LTFT, as were 11% of males.8 We need to stop assuming that one newly qualified doctor equates to one full time equivalent doctor for a lifetime, taking into account attrition and LTFT working, and plan training numbers accordingly.

Doctors working “part time” often do what would still be a full time 37.5 hour working week in other NHS clinical professions. For example, a GP working three 12 hour clinical days, with admin on top, is hardly shirking. Doctors in all NHS sectors take on other roles alongside their clinical commitments—in education, management, research, quality improvement, or external professional bodies—but this work isn’t visible to the public.910

Reducing hours is often a reaction to stress, burnout, or unsustainable workloads, or it’s a practical necessity owing to parenting or caring responsibilities. Given that the UK already has fewer doctors per 1000 than most countries in the Organisation for Economic Cooperation and Development11 and that many NHS doctors report burnout or moral distress from unsafe workloads,12 I’m not sure how forcing people to work five full clinical days a week, plus out-of-hours on-call, would help to tackle this or retain staff. After all, doctors have transferrable and exportable skills.

In reality, most doctors don’t leave the profession. The General Medical Council’s annual survey reports that over 90% of medical graduates working in the UK remain in medicine, and most still go on to full time employment.13 And the NHS in the four nations is in effect a monopoly trainer for anyone wanting to complete their postgraduate training in the UK.

As for the remarks I keep seeing about the £250 000 training costs: in 2016, newly qualified UK doctors paid an average of £64 000 in fees or maintenance loans, finishing university with debts of around £80 000.14 Of course, medical degrees are expensive, given their duration and the amount of lab based and clinical placement training. But in return the taxpayer gets doctors who, for the most part, devote decades of public service to the NHS, even though their skills are eminently exportable in a global medical labour market.

Doctors may have a vocation, and they may be public servants, but they’re not conscripts—and yes, some will want to have a work-life balance or raise children, or they may have to adjust working patterns for their own health. A strategy of “pay them mean, keep them keen” won’t work in terms of recruitment, retention, or morale.15

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