Published: 07/02/2002, Volume II2, No 5791. Page 24 25 26
The government is committed to increasing the number of doctors in the NHS by 9,500 by 2004. Two thousand of these extra doctors will be GPs, the other 7,500 will be consultants. Finding them is essential for the NHS plan to succeed.
But these extra doctors will only marginally improve the density ratio of doctors in the population. This has been much cited as a key comparative factor in judging the adequacy of healthcare provision between countries. Statistics recently compiled by the Organisation for Economic Co-operation and Development show that the UK stands only above Korea, Mexico and Turkey in the league of available practising doctors.
It comes bottom of the table of countries in which Hungary, Greece, Ireland and Poland are all ahead (see opposite).
The planned net increase in consultants by 2004 is 3,000 - the other 4,500 of the 7,500 are already expected to come on-stream. The additional 1,000 medical school places will only increase the number of available consultants by 2011-12. For GPs, the increase announced is only marginally more (0.7 per cent) than the total already planned for 2004.
Where will the extra doctors be found to produce the net intended increases by 2004?
The government looks to international recruitment (chapter 5 of the NHS plan). But initially, it ruled out drawing doctors from developing countries and depleting their medical resources. The NHS plan envisages drawing on the 'surpluses of trained doctors in some European countries', using short-term contracts to boost the number of consultants and 'the overall number of doctors in the next three years'.
Professor Sir George Alberti, president of the Royal College of Physicians and a member of the NHS modernisation action team, was reported in Hospital Doctor (20 July 2000) as saying that more European doctors can be 'used to fill the gap'.
This optimism may be misplaced. European countries have provided very few of the overseas doctors employed in the UK. In the decade 198999, 5-6 per cent of doctors working in Britain had primary medical qualifications gained in the nonUK European economic area (EEA).Yet 23-25 per cent of doctors working in Britain had gained their primary qualifications in non-EEA countries.
About half of those who qualified outside the EEA are training-grade doctors, who will leave the UK when their training is completed.
But the critical number is that in 1999, 16 per cent of consultants qualified in non-EEA countries, while only 4 per cent of consultants qualified in non-UK EEA countries.
The UK has never looked to Europe to supply it with medical consultants, yet it is expected that in the next three years Europe will furnish us with a number roughly equal to that supplied over the past decade by non-EEA countries.
Projections from an important study by the permanent working group of European junior hospital doctors, Medical Manpower in Europe by the year 2000, indicated that a moderate general increase in demand for doctors within the EEA would produce a broad equilibrium by the year 2000.Measures have been taken in some notable overproducing countries to reverse the oversupply of doctors by restricting medical school places. This has contributed to a reduction in the expected overall annual growth rate in medical manpower in the EEA from 2 per cent in 1995 to less than 0.4 per cent by 2004.
The medical staff the NHS needs to attract from Europe are already active as consultants or equivalent practitioners and GPs.
It will be difficult to entice them from the better resourced health systems and private practice facilities in which they work and prosper.
Cut above: French doctors demonstrate against cuts, but would they prefer the Unless the NHS intends to improve vastly pay and employment packages to lure these doctors to Britain on the short-term contracts that are envisaged, the pool of doctors from which it would look for recruits does not fit the bill. In Italy, Spain, Greece, Germany and Austria there will continue to be a 'surplus' of doctors (measured by positive unemployment rates).However, they are not specialists trained to the level of skill and experience that would enable them to step into an NHS consultant post immediately.Most doctors who can be readily acquired from Europe would need extra training and experience to reach the competencies required of consultants and GPs in the UK.
An Anglo-Spanish pilot scheme agreed between both country's governments has allowed recruitment of doctors and nurses from Spain. Forty Spanish doctors have been brought to Merseyside area on oneyear contracts.However, they are employed as non-consultant specialists, owing to their lack of training and the need for supervision.
It is not necessary to look exclusively towards Europe to fill the manpower gap.
There is a home-grown source of recruitment in the present non-consultant grades of doctor. At the very least, if the Department of Health decides to recruit 'surplus' doctors who require top-up training from EEA countries, it should offer the same chances to doctors already in the NHS system.
The government and NHS have belatedly recognised this. The news of modifications to the implementing legislation of the European specialist medical qualifications order is a welcome measure, if overdue.
Britain recently completed implementation of this order, which enacted common recognition of medical qualifications conferred by EEA countries.
In the transitional stages, a limited opportunity was granted to existing doctors who had not followed the highly prescribed training pathways to consultant status to be assessed on the basis of their often considerable years of experience working as locum consultants and associate specialists.
A favourable assessment by the relevant specialty royal college enabled doctors to be registered as eligible to work as consultants, or to be classed as requiring further identified training of one year, before reaching the required standard.
Parliament modified the original legislation to allow medical experience gained in non-EEA countries to be counted, but very few of these doctors obtained the kind of assessment that allows them to work in a substantive consultant post or to undertake the one year of extra training to reach the officially prescribed standard.
Yet many of these doctors continue to work as consultants on long-term locum contracts or alongside consultants, performing specialist roles.
It is not possible to estimate accurately how many of these doctors may have been excluded because of the institutionalised tendency of professional manpower systems to control the numbers reaching top positions.
It remains a mysterious anomaly that doctors who have spent many years performing the work of a consultant, covering so-called vacant posts, have been denied recognition to hold the post they have covered so competently. The short-term needs of the NHS plan for extra consultants have created the grounds for a pragmatic review of the position of these doctors. Any change to the legislation must not repeat the old mistakes.
Human resources management has not been achieved in the UK medical profession. To plan and develop manpower, it is necessary to know what skills and potential already exist and are available for further development.
No database exists within the NHS or in the royal colleges to allow the skills of the existing body of non-consultant doctors to be assessed and developed. In view of how much the health service depends on these doctors, this is an unacceptable deficiency. One thing that is clear is that most doctors in these grades are from nonEEA countries.
There are signs that the NHS might after all be turning to the Indian subcontinent as a source of extra doctors. No doubt this will, as before, produce an ample supply. But a radical change is needed in the way the system has treated overseas doctors.
The reality for overseas doctors is, it seems, a deeply institutionalised racism. The King's Fund report Racism in Medicine relates, depressingly, that black and Asian doctors are far less likely to become consultants, and if they are GPs they are more likely to find themselves practising in inner-city deprived areas and in small or single-handed practices.
Indian and African doctors pass the same exams yet do not achieve the same promotion in their profession as their non-Indian and African colleagues.Any acceptable attempt to address the gap must include properly structured exchange programmes, with the emphasis on 'exchange' and development.
Doctors must not be left floundering in a system that is indifferent to their long-term career and development needs. For too long, the exchange has been one-way. It would help supplying countries if the export of medical staff was balanced by doctors returning with considerable experience, knowledge and skills, from which their own countries could benefit.
In a 'globalised'world, it is not acceptable for medically qualified personnel to be taken out of their own countries without government efforts to redress the balance and tackle the impact on the health economies of affected countries.The way our government and the NHS choose to address the medical manpower gap here can contribute to tackling key social and economic development issues in other parts of the world.
The government and the NHS must grasp the full extent of the problem and the opportunities.A short-term boost to medical staff numbers along the same lines as in the past would be wrong.There is an opportunity to rectify the injustices and exclusion that have been the hallmark of the established medical manpower system.The staffing gap gives the government the chance to create structured exchanges of medical staff that will improve global health and social development objectives. l REFERENCE 1Department of Health.
Statistical Bulletin - Hospital, public health medicine and community health medical and dental staff in England 1989-1999 (May 2000).
Romesh Gupta is professor of ethnicity and health, Bolton Institute, Manchester, consultant physician at Chorley and South Ribble trust and national vice-chair, Overseas Doctors Association.
Joseph Chattin is northern regional officer, Hospital Consultants and Specialists Association.
Sam Lingam is professor of medical education and consultant community paediatrician, St Anne's Hospital, London, and chair of the hospital doctors' forum, Overseas Doctors Association.
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