Intended for healthcare professionals

Opinion Acute Perspective

David Oliver: NHS England’s proposals to aid junior doctor retention are basic good practice presented as radical ideas

BMJ 2024; 385 doi: (Published 22 May 2024) Cite this as: BMJ 2024;385:q1120
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

On 25 April, with the pay restoration dispute between the BMA’s Junior Doctors Committee and the government still unresolved, NHS England published a document on Improving the Working Lives of Doctors in Training.1 This was aimed at “tackling the concerns of doctors in training and staff who rotate.” But how radical, credible, or new were the actions proposed?

The document recommends improving rota management and deployment, reducing duplicative inductions and pay errors, and better HR support. Key actions include protecting training time for learners and educators; tackling issues to help “foster a sense of wellbeing and belonging”—for instance, around car parking, lockers, and availability of facilities; and using free e-learning and the NHS staff digital passport to make online statutory and mandatory training shorter, simpler, and more transportable between organisations.

So, what’s wrong with any of this? Well, the things that weren’t included. There’s no mention of pay, nor of hard financial resources to support these initiatives—such as how, in practice, do we protect the time of teachers or learners when up against service pressures and rota gaps? There’s no mention of the considerable cost of postgraduate exams and portfolios to doctors themselves, nor of current bottlenecks and medical unemployment at various stages, from qualification through to job seeking on completion of specialist training.

There’s nothing about the considerable gaps in the detail of NHS England’s long term workforce plan,2 such as expanding training numbers to match the growth in medical school places. Nothing reflecting the current concerns about physician and anaesthesia associates and their impact on doctors’ training and job opportunities. And nothing on the complete uncertainty for many foundation doctors about which part of the country they’ll be sent to,3 with a lack of control over destination that looks more like military deployment than medicine, only with no breaks between tours of duty.

What’s more, I don’t think that it’s in NHS England’s gift to enforce or police most of these ambitions, which mostly sit at the level of local deaneries and postgraduate schools or with managers in HR, payroll, estates, and IT in local employing trusts. And, crucially, much of this lies within the responsibility of senior doctors employed in key management and educational roles at those organisations. The quality of implementation and the commitment to action will continue to be a postcode lottery. And some trusts and health economies are under much greater pressure from workforce gaps and demand than others.45

A whole set of very similar ambitions and promises were set out by NHS England in 2016-17 in the wake of the previous junior doctors’ contract dispute—Enhancing Doctors’ Working Lives,6 with annual progress reports since then.7 If it had been that influential, we wouldn’t now be revisiting many of the self-same proposed actions. If we were truly serious about junior doctors’ welfare, rather than seeing them as transient, service provision cannon fodder, we wouldn’t keep setting out intentions that lead to no concrete change. Seeing this list is, to quote the baseball legend Yogi Berra, “like déjà vu all over again.”8 And it speaks volumes that NHS England sees paying rotational junior doctors the correct rate and correcting errors quickly, rather than drawing the process out, as some kind of magical innovation.

Sadly, I don’t think that enough will happen to any significant degree to be noticed by the junior doctors it affects. I doubt that it will stop people wanting to leave the NHS or help the doctors who are already burnt out and disillusioned. I speak frequently to junior doctors I work with or supervise: their reaction ranges from unaware to unimpressed.

Most importantly of all, the proposals are targeted towards doctors who rotate between different employers, towns, or regions. We need a much bigger discussion about the whole nature and necessity of rotational training in its current format. I personally think that rotation has significant value in training, but plenty disagree. NHS England’s document ducks that debate, as it does so many other issues.