LOOKING ASKANCE

Published: 30/05/2002, Volume II2, No. 5807 Page 20

For decades, the Department of Health has pretended to plan the medical workforce by regulating the supply and demand of doctors. This has led to recurrent shortages and surpluses. Labour's 'planning' has been desultory, with mandarins dreaming up numbers to meet ministers' desires to expand medical school intake.Now, medical workforce planning looks set to be abandoned in favour of market forces.

Demand for doctors is ultimately determined by the nation's income and its willingness to fund healthcare - and there has been a huge increase in NHS cash recently.Yet this increase arrives at a time when many doctors are unhappy.

Hospital doctors are pressured to work harder to meet the government's patient-access targets. Following Bristol and other scandals, these doctors are also required to improve quality.

Most clinicians are arguing they need to work slower and treat fewer patients to improve quality.

This trade-off is affecting activity rates, but Whitehall seems unaware of these problems.

GPs, despite a threefold increase in the number of practice nurses in the last decade, remain adamant that work pressure is excessive and new recruits want contract flexibility (which means fewer hours of work).Ageing GPs want to retire if they can increase their pensions following stock market declines.

With doctors wanting to do less, ostensibly to enhance the (usually unmeasured) quality of their work, and the increase in NHS expenditure, how will the services be delivered?

Soon, continental surgeons will jet in to exploit unused NHS facilities (eg over weekends), pitching prices between NHS and private sector levels. This competition will put downward pressure on the price inflation evident as NHS consultants exhibit reluctance to work extra hours.

The government has decided to leave it to the market. This policy is risky. It will encourage foreign doctors to work in the NHS, and many are now being recruited from continental Europe and elsewhere. The several thousand refugee doctors resident here will be retrained as quickly as possible.

However, the training and practice of these doctors will have to be regulated with care.

Consultant appraisal exists in all NHS hospitals. This needs to be linked into the private sector and kept independent of those wishing to capture and neutralise it. Appraisal has to be augmented with revalidation of all practitioners every five years.

This consumer protection has to be complemented by more sophisticated performance management of all practitioners, and this requires integrated systems of data collection to cover all public and private work.

If the government thinks abandoning workforce planning removes the need to regulate the market, it is wrong. And given the profession's failure to control the practices of Shipman and others and to not measure, let alone manage, medical errors, we must be suspicious of medically led regulation.

An increase in such regulation will deprive patients of care. Such opportunity costs are also evident in the new contract proposals for GPs and consultants. Given the doctor 'shortage', there is a risk doctors will get double-digit pay increases.What will be the benefits of such generosity? One goal of pay increases is to end early retirement.Will pay increases lead to higher activity levels? With doctors wanting to work slower to improve care, it is unlikely activity will increase.

A final argument in favour of pay increases is that higher remuneration levels may increase the inward migration of practitioners from the continent.

This is possible, but would targeted rewards (eg temporary help to assist immigrants to set up in UK practice) be more costeffective than general pay rises?

Questions about such alternative policies seem unlikely to be put, let alone answered.Government pledges to renovate the NHS have left Whitehall anxious. Policies such as the abandonment of workforce planning are being adopted with little appraisal.

Delivering the NHS Plan is ambitious and barely touched by human thought, let alone evidence. It highlights the need for workforce increases but seems more dependent on a magic wand than careful design.However, it is a chance for all to contribute to policy by producing alternatives to the government's more insane choices. l Alan Maynard is professor of health economics at York University.