The government's comprehensive spending review allows for health secretary Frank Dobson's promised increase in the number of doctors and nurses in the NHS by 7,000 and 15,000 respectively, with a further 6,000 nurse training places. The urgent problem of sourcing these doctors and nurses has been raised by the British Medical Association, the Hospital Consultants and Specialists association and the media at large. Given the present situation, workforce planning is a particularly important issue. Those engaged in this process must take into account a question Goldacre recently asked: should we aim for UK or European sufficiency in terms of the NHS workforce?1
The recent British presidency of the European Union and increased moves towards economic and monetary union have again placed the debate about an integrated Europe high on the political, social and healthcare agenda.
Integration will not affect the formal structure and organisation of European health services. But, as one of the major areas of economic activity in all member states, health services could potentially be affected in a number of areas - most noticeably by the impact of labour mobility on the supply of doctors and nurses.
Investigating the impact of labour mobility on health services is important in the context of both the spending review and contemporary workforce planning. Workforce planning is, however, a difficult and neglected area, and the adoption of a European dimension is a complex and undervalued process.2 There is little systematic collection of data on the numbers of doctors and nurses moving into or between member states, and the implications of this mobility for European health services are not known.
There is also a fundamental lack of useful data on the number of doctors and nurses in the UK who qualified in the European Economic Area and their career intentions. National data sources show that, at 28 July 1998, there were 7,010 European qualified doctors (excluding those from Ireland) listed on the General Medical Council's full register. This figure increases to 12,511 when doctors from Ireland are included (see figure 1).
Importantly, in the year to December 1997, the number of new registrations of overseas graduates from both inside and outside the EEA declined. There were 2,084 new registrations of doctors from the EEA in 1996 and 4,047 from overseas outside the EEA. During 1997, these figures dropped to 1,860 and 3,678 respectively.
Figure 2 illustrates the number of new admissions of nurses qualified in the EEA to the United Kingdom Central Council for Nursing, Midwifery and Health Visiting's professional register between April 1996 and March 1997. By the end of April 1998, there were 2,614 EEA qualified nurses registered with the UKCC.
In terms of workforce planning, registration data from the GMC and UKCC has limitations. It tells us little about the actual numbers practising, their whereabouts or their career intentions. The most recent and disaggregated data from the national medical census, undertaken by the NHS Executive and dated 30 September 1996, illustrates that EEA doctors, on average, constitute 10 per cent of doctors at senior house officer grade in England and Wales.
In-depth investigations into the profile of EEA doctors and nurses at a local level are now required. Indeed, the contribution that EEA healthcare professionals make to the total NHS workforce needs careful consideration for a number of reasons, not least because of the spending review. North West regional office commissioned a study in this area in August 1997.
The career intentions of EEA doctors are also reported to be changing.3 Fewer European doctors in training now are likely to spend their whole careers in the UK. A recent study, undertaken by the permanent working group of European junior hospital doctors, indicated that the deficit of UK doctors will continue to increase while medical unemployment in Europe will continue to fall. Historically, nearly all European countries produce too many doctors. The exceptions are the UK and the Nordic countries. Intense competition for postgraduate training positions is, therefore, commonplace. As medical unemployment subsides on the continent, however, European graduates will no longer need to come to the UK to train.
This is particularly important considering the current discrepancy between the demand for and domestic supply of doctors in the UK reported by the medical workforce standing advisory committee last December. While favouring self-reliance as the long-term goal, the committee recognised that substantial numbers of overseas doctors would be necessary in order to meet the expected demand for healthcare. This approach has been supported elsewhere.4
Recent research has highlighted that, increasingly, UK graduates show a lack of commitment to practising medicine in the UK.5 A decrease of 13.5 per cent in the number of newly qualified UK doctors who said they would 'definitely' or 'probably' practise in the UK between 1977 and 1993 has been reported. The large percentage of respondents in 1993 who were undecided about whether or not they would practise in the UK was notable compared to 1977, with up to 60 per cent expressing the desire to practice overseas at some point. Increased disillusionment with working conditions, the rigid career structure, shortage of opportunities for flexible working and lack of career advice have also been reported.6
Changes to the structure and organisation of postgraduate training programmes as a result of the Calman proposals suggest that existing junior doctors will spend fewer years in training, less time directly providing services and more time in alternative forms of educational activities. This will reduce the number of hands-on junior doctors in the NHS, a problem compounded by the potential implications of the EU working time directive as in the past junior doctors have been exempt from complying with the 48-hour working week.
The contribution that EEA nurses make to the NHS should not go unmarked, particularly in light of the severe shortage of nurses in the UK - a problem that would be worse if not for the 'all-time high in recruitment of nurses from overseas' reported by the UKCC.
Despite the spending review, the convergence of these factors could mean fundamental problems for NHS staffing at the beginning of the next millennium. The potential shortfall of European medical staff coming to the UK that the European junior doctors' study implies seems to have gone largely unnoticed.
Were the contribution of European medical staff to be curtailed or in any way inhibited, NHS staffing could face an extremely difficult future for several reasons. Not least of these is that the 7,000 additional doctors prescribed in the government's review can only come from abroad.
There are few published studies and there is a lack of published information on the numbers of European qualified doctors training in the NHS. Their experiences of training and their future career intentions should be assessed urgently.
There is growing evidence that integrated workforce planning must take full account of the European dimension. In this context, the recent announcement of 7,000 more doctors, 15,000 nurses and 6,000 more nurse training places requires translation into an action plan that takes account of British, EEA and overseas healthcare professionals.
1 Goldacre M. Planning the United Kingdom's medical workforce. BMJ 1998; 316: 1846-7.
2 Orchard C. Spreading the load. Health Service J 1998; 108 (5594): 36- 37.
3 Permanent Working Group of Junior Hospital Doctors. Medical Manpower in Europe by the Year 2000 - from surplus to deficit. Copenhagen: Danish Medical Association, 1996.
4 Maynard A, Walker A. The Physician Workforce in the UK: issues, prospects and policies. London: Nuffield Trust 1997.
5 Lambert T, Goldacre M, Parkhouse J. Intentions of newly qualified doctors to practise in the UK. BMJ 1997;
6 Lyall J. Doctors' orders. Health Service J 1997; 107 (5556): 12.