The views of a new generation
Last year, the North West Deanery surveyed its 4000 trainee doctors and dentists about the NHS reforms, and found that 98 per cent had not participated in any consultation. That makes the survey the first time their voices have been heard.
Amongst many striking findings are that 60 per cent of respondents felt they did not understand the reforms well enough. In particular, they felt poorly informed on the effects of the reform on their patients, their work and their training. Many also expressed fears for their careers as a result of the reforms. Overall, it is clear we need to find better ways to support trainees through the transition, and to ensure their voices are heard in consultation in future.
There have been several consultations on the reforms, but these were targeted at clinicians in general rather than trainees. Trainees were included in the BMA’s 2011 survey of its members in England, but only as part of their wider professional group. The North West Deanery therefore felt it was imperative to directly consult the future medical and dental workforce.
Between 5 July and 5 August 2011 every medical and dental trainee in the deanery had the opportunity to take a short online survey. Each was sent an invitation from the postgraduate dean’s email address and then two reminders at weekly intervals. Comments were invited in response to each question. Responses were gathered from all training grades and a wide variety of specialties. Surveys were completed by 1694 doctors and 34 dentists - a 43 per cent response rate.
Support for the reforms
Two per cent of respondents wholly supported the reforms, 57 per cent supported them in part and 41 per cent did not support them at all. Those supporting the reforms in part typically made positive comments about greater clinician input. However, they often expressed concern this is not being introduced effectively.
Respondents who did not support the changes said GPs should not be given control and are doctors rather than managers. Some believed GPs will be overwhelmed, and will attract criticism no matter how well they do. There were anxieties about doctors assuming the role of business managers, and about increasing privatisation. Some trainees said patients will become “numbers on an accountant’s spreadsheet”.
Comments were made about constant reforms by successive governments, who do not understand which changes could be truly beneficial, nor the potential negative impact of its proposals, said others. Respondents acknowledged that many areas of the NHS would benefit from improvement, but felt the reforms did not accurately address these problems. One said:
“If a car needed a new tyre, you wouldn’t change the oil. There are problems with the NHS, but I’m unsure whether the current reforms will actually fix the problem.”
Understanding the reforms
Three per cent felt they understood the reforms in general very well, while 37 per cent felt their understanding was sufficient. The remaining 60 per cent said they did not understand the reforms well enough. They were unclear about the effect on patients, their work and their training. Many were frustrated at being unable to stay informed, saying information was not easily accessible and they had no time to seek it out. Some felt more information was being directed towards GPs than hospital staff:
“I feel as a trainee I have been wholly excluded from the proposed reforms. No-one in the NHS seems to be able to understand the reforms, the gravity and repercussions on job planning in the future.”
There was concern amongst trainees at how little, as the leaders of the future, they were being involved in the decision-making process.
Ninety eight per cent of respondents had not participated in any consultation exercise, making this survey the first time their voice has been heard. Of those who had participated, most had either completed the BMA survey or responded via the Department of Health’s website. Others had spoken out by attending a local meeting, by raising the reforms with their local MP or by responding directly to David Cameron’s public letter.
Just 1 per cent said they believed patient care would be improved extensively, while 18 per cent thought it would improve to a certain degree. A quarter did not believe patient care will be improved and 16 per cent felt the reforms would make things worse for patients. Thirty nine per cent said they were unsure.
Some trainees suggested the reforms would benefit from a pilot stage, while others worried that improvements will be cancelled out by deterioration in other areas. Trainees generally believed the changes were a cost-cutting exercise which will negatively impact upon patients.
Twenty three per cent believed more medical trainees will become GPs while 21 per cent believed the opposite. Fifteen per cent thought the reforms will not influence specialty choice while 41 per cent were unsure.
A number felt a career in general practice will be more attractive and stable than in hospital medicine owing to the control the reforms afford to GPs, particularly over budgets. One respondent said:
“There will be more wanting to become a GP as there will be more power and availability to make change in these roles. The typical hospital consultant will have very little chance to improve services and make change.”
Other respondents, including medical trainees who believe fewer will want to enter general practice, spoke of anxiety about the control GPs will have. They were concerned that GPs have not been trained for their new role, and do not welcome it. A number of trainees felt unprepared and unwilling to become managers:
“We are not adequately trained as doctors to undertake the activities and responsibilities proposed in the reforms.”
Only three per cent of dentists believed more will want to become general dental practitioners as a result of the reforms, while 35 per cent felt fewer would. Twenty three per cent did not think the reforms will affect career choices.
Sixty four per cent of respondents said the reforms will impact on their career, and almost all of their comments indicated a negative impact. Problems anticipated by respondents included increased competition, increased workloads, reduced staffing numbers and poorer training - all of which would impact negatively on practice. Some said they expected a growing proportion of their peers to leave medicine altogether.
Thirty six per cent felt the reforms would not have an impact, and made little comment.
Fifty three per cent of dental trainees said the reforms would have an effect; 47 per cent that it would not. One said:
“The systems are not for the enthusiastic [dental] practitioners but more for those who are happy to be told how to work and how to treat our own patients.”
The survey’s response rate over a one-month period is felt to be acceptable compared to the BMA’s 2011 survey response rate of 9%. The rate may be partly attributable to the questionnaire invitation and reminders coming from the postgraduate dean’s email address, which conveyed the importance of the survey. An online survey was a convenient response tool, and the length was kept as short as possible.
When responses are compared to those of BMA members, some differences can be observed. Only 3 per cent of trainees felt they understood the NHS reforms very well in general and only 37 per cent believed they understood them sufficiently.
By contrast, 10 per cent of BMA members felt they knew a great deal about them and 52 per cent a fair amount. Eighteen per cent of the BMA’s respondents were broadly supportive of the reforms, in comparison to 2 per cent of trainees.
Trainees’ lack of understanding may explain why so few have participated in any consultation - they feel insufficiently equipped to comment. However, our high response rate indicates that despite their lack of understanding and participation in consultations, trainees want to be heard.
In reality, a wealth of information on the reforms is available to trainees. It is unfortunate they feel they have little time to seek out and digest this, and their lack of understanding is a concern.
Regardless of whether trainees’ perceptions are accurate, it is important to address their anxieties. It seems that the NHS reforms may be influencing trainees’ career choices even though they are not properly understood. Career decisions based on assumptions and misunderstanding are not ideal.
Although this survey was in the North West it was about national proposals, so it is possible that the wider trainee population share similar concerns. If so, this suggests the new NHS could have staff for many years to come who need reassurance about the structures they have to work within.
Further research into how to support trainees through these changes would be beneficial. Research into how the trainee workforce receives information and how they could be better informed in the future is also recommended. Finally, further investigation into how boosting participation in consultation could improve trainee engagement in future is essential.
Dr. Catherine Tregoning, Postdoctoral Research Fellow and Chartered Psychologist; Professor Jacky Hayden, Dean of Postgraduate Medical Studies, both at North Western Deanery, NHS North West.