Article by Sophie McManus

We all know the NHS is in crisis; escaping from the crisis will require a much more serious effort to ensure that the NHS has the right numbers of staff with the right skills. Increasing the number of doctors in the NHS should be a priority.

Status Quo: Crisis

‘The NHS is in critical condition’ is the conclusion of Lord Darzi’s report into the state of the NHS. This condition manifests as a laundry list of woe: agonising A&E waits, over seven million people on elective hospital waitlists, absolute and relative reductions to the number of years we spend in good health (with four million out of work due to ill-health) and sustained UK underperformance across health outcomes relative to other OECD countries. Public satisfaction with the NHS has never been lower. As Darzi’s report notes, the crisis state of the NHS is not only due to what has happened within the service itself; the backdrop to NHS failings is a nation in worse health. Our population continues to age, exacerbating multimorbidity and overall frailty, which in turn increases care needs and associated cost. Deprivation-related conditions such as obesity remain a pronounced challenge, as do associated diseases including diabetes, which alone represents 9% of NHS budget. This presents a vicious circle.

Arguably, the primary reason that the NHS has slipped from its previous world-leading status is systematic underinvestment across the board, i.e. in staff and infrastructure. Poor diagnostic capability due to insufficient staff, beds or diagnostic equipment leads to delayed access to effective treatment and results in worse outcomes, not least poor cancer survival rates. Numerous evidence-based perspectives^1,2,3 align with the report delivered by Lord Darzi in highlighting underinvestment as the root cause for the mess we are in.

Treatment Plan?

The 99% Organisation’s 2023 report, The Rational Policy-Maker’s Guide to the NHS, written in collaboration with bodies including Keep Our NHS Public, Every Doctor and the National Health Action Party, outlined how a return to appropriate funding coupled with better prevention and tackling the social determinants of ill-health could restore NHS performance to a gold standard for effectiveness, equity and efficiency. Lord Darzi’s report also points to the NHS having been ‘starved of capital’ in recent years.

Equally, the ‘prevention rather than cure’ adage serves as a salient reminder that community and general practice should act as reinforced pillars of the system. During austerity, public health budget cuts led to more people living in preventable ill-health, thereby increasing strain on GPs and hospitals. There have been calls to restore the public health grant in order to improve upstream health determinants, thereby reducing colossal pressure on the NHS.

But lack of funding is not the only issue: the NHS has a major issue of workforce planning which the new government has not yet addressed.

From the Sublime to the Ridiculous

The Hunger Games of Doctor Jobs

Competition ratios published last month for specialty doctor training make for eye-watering reading. 15,036 doctors applied to 4096 GP training positions, meaning that over 10,000 were not offered a GP trainee post. Meanwhile the Health Foundation recently concluded that the UK is short by at least 4,000 GPs, with projections that this shortfall could reach over 8000 by 2031. (In a Kafka-worthy twist there have been reports of unemployed GPs approaching charities for help to pay the bills.) Applicants who wish to become GPs with a special interest in public health face a ratio of over 100:1 per place.

Specialty training competition ratios are high across the board, not just in primary care. An aspiring A&E doctor will have to beat six other candidates to get into training, as will a wannabe obstetrician. A doctor gunning to become a cardiothoracic surgeon will be up against 44 of their peers.

Unlike other countries, such as the USA and Australia, the UK does not prioritise UK-trained doctors for NHS jobs due to immigration rules. This has also contributed to competition for medic jobs at all levels and stages of training.

What do aspiring specialty trainees do if they miss out? They can reapply in a second application round, although the odds will necessarily be worse than in the first round. They may seek a non-training job – also thin on the ground – while beefing up their portfolio, before reapplying (possibly over a period of several years); they might move abroad, or they might leave medicine altogether, with the BMA estimating the number of ‘premature’ exits as over 15,000 in 2022.

The Rise of the Physician Associate

While medical competition ratios for doctors have been increasing, there has been a parallel increase to the number of physician associates (PAs) practising – a 27-fold increase in 2023 vs 2015. PAs are intended to support doctors in hospitals and GP practices and can practise after two years of training (medical school lasts five to six years, and doctors must then complete a further 5-10 years of postgraduate training before reaching GP or Consultant level).

Upon qualification, PAs may earn £10,000 more than a newly-qualified doctor, but they are not supposed to work without direct supervision by a trained doctor, with doctors remaining responsible for diagnosis and management. However, there have been cases of PAs being directly substituted for doctors (for example in GP surgeries and in A&E departments) and working unsupervised. Indeed, there have been several high-profile cases involving PAs seeing ‘undifferentiated patients’ (presenting with a new symptom, without a clear diagnosis), resulting in serious harm and even avoidable deaths.

One such case was 30-year-old Emily Chesterton, who was misdiagnosed twice by a PA. On each occasion she believed that she was seeing a GP. The PA she saw initially deemed her swollen leg to be a sprain; on her second visit she was offered anxiety medication. She died from a pulmonary embolism. The PA who misdiagnosed Emily was found to still be practising as a locum (temporary staff member) in London after the termination of her contract with the GP practice in question. Last month the BMA backed Ms Chesterton’s family in a legal case against the General Medical Council that will fight for improved regulation of the PA role.

Another issue regarding PAs relates to rotation. PAs are considered permanent staff, so consultant doctors may prefer to teach PAs how to perform procedures over resident doctors or specialty trainees, who are obliged to rotate to a new hospital every few months. In such a situation resident doctors could lose opportunities to upskill, although they would still be expected to step in for the most complex procedures.

Recently, NHS Grampian has been accused of ‘blurring the line’ between PAs and doctors by providing them with the same uniform. This year, a British Medical Association survey revealed that 55% of practising doctors believe that PAs increase rather than alleviate medic workload, almost 80% stated that they were concerned that a PA or AA they work alongside worked beyond their level of competence, and 87% said that the way PAs work present risks to patient safety. The number of PAs continues to increase regardless, with the long term workforce plan setting out a target to employ 10,000 PAs by 2037.

Sticking Plasters

The last government recently increased medical school places. However there appears to be little point in such a policy given that there are insufficient jobs for such graduates or their more experienced colleagues to work in. Indeed, this year over 800 medical school graduates – around 10% of the total – faced significant delays to receiving their first job offer.

Conclusion

Lord Darzi’s report outlines key themes for a ten-year plan for the NHS: while the need for more staff is implicit, the report does not explicitly reference the paucity of posts available to doctors in the UK, particularly at specialty levels. Creating doctor jobs should be a top priority for the government in order to reverse part of the damage that has been wrought on the nation’s health by sustained NHS underinvestment.

Sophie McManus, the author of this article, is a 99% member and a life sciences consultant with a PhD from Cambridge and an undergraduate degree from Oxford. Important contributions were provided by two doctors currently practising in London with over a decade of clinical and academic experience between them. They trained in Oxford and Cambridge respectively.

Notes:

1. The Rational Policy-maker’s Guide to the NHS, 2023 report, 99% Organisation’s 2023 report, link
2. The Health Foundation, 2022 analysis, link
3. Institute for Fiscal Studies 2022 report, link