Here’s an interesting graph.
It shows the number of junior doctors taking up specialist training jobs once they’ve finished their foundation programme (the two years of compulsory rotations once you’ve finished medical school). The numbers are falling, a lot. Nine years ago more than 4/5 people were staying in training posts, last year it was less than half that. The figures haven’t been published for this year yet, but I just went through the process, and anecdotally among my friends the trend will continue, and we might even be below a third this year.
Why aren’t doctors taking up training posts? Morale is at an all time low. Long unsociable hours, mediocre pay, tedious busywork and limited training opportunities. Hospitals are mostly grim places to work with no rest facilities, rubbish food and outdated technology. This is ultimately what the strikes of 2016 were about. I’m sceptical of the patient safety arguments, but that’s fine, crap working conditions are the cause of all industrial action, and their case was reasonable. A cohort of the best and brightest graduates compared themselves to their non medical peers and saw they were overworked and underpaid. A monopsony employer was holding wages below market levels.
So what are all the doctors doing? A few years ago the trend was for disappearing to Australia and New Zealand, and lots still do, but the numbers doing this haven’t really changed. The big increase is in people taking ‘appointments in the UK’, and ceasing to practice medicine altogether. These appointments in the UK are people taking locum work.
Locums are medical supply teachers, filling gaps in the rota whenever they fancy picking them up. As doctors don’t take up training posts there are more rota gaps and the demand for locums increases. Pay increases to attract them. The locum hourly rate is much higher than that of regular trainees, this from the BMJ gives an average of £50, and that tallies up with my experience. By comparison, this is about twice my overall hourly rate for a full time training post at the same level of responsibility.
The rota gaps left behind by doctors not entering training also means training jobs are more unpleasant, and even more people turn to part time locuming. It’s a vicious cycle. Push factors from burnout and pull factors from money. Why take a full time A&E training job when you could earn the same money for half the hours freelancing, then run away to Bali to recharge your broken brain whenever you like?
The only downside is that locums are limited in their career progression. There are some ways around it, but for the most part to become a consultant you need to do training jobs. The jobs naturally don’t offer very much training, it’s all just service provision. In practice the trade off is ‘come and do the same job as a locum for worse pay for a few years in the hope you’ll earn a bit more in the future’.
The government tried to crack down on locum spend with the classic free market Tory solution of a price cap, which did succeed to a limited extent. I suspect a lot of the reduced spending is due to most doctors now directly negotiating with hospitals via their own staff banks, and cutting out third party locum agencies. London tends to fill its training posts, as middle class twenty somethings love London. There’s fewer rota gaps there and more doctors willing to fill them so they can get away with mostly sticking to the cap. Everywhere else rates are still pretty great though, and lots of people commute out. Ultimately though hospital management need to make a choice between breaking the cap and extra deaths in an understaffed hospital, and they tend to make the right one. Crucially, though pay caps have controlled spending somewhat, they haven’t stemmed the bleeding. Even falling pay can’t tempt doctors back into the fold.
To broaden my point out somewhat, locuming is the quintessential millennial career. The gig economy for medics! There’s little career progression, but most of us in any careers don’t see much of a future. We can’t imagine ever owning a house or a future for our two point four kids, just endless work to prop up the boomers. So why not embrace aimlessness with an endless gap year?
But what does this say about the future of medicine as a career? We’ve been suffering real term pay cuts for years, and if this continues it will damage the status of the profession and reduce the quality of applicants. The rich genius doctor as pillar of the community with his good lady wife indoors is already a thing of the past, but we’ll move in the opposite direction. Medicine as a career for quite clever people who aren’t especially interested in money or status, but want part time work with ultimate flexibility.
I don’t want anyone to think for a moment that I’m criticising locum doctors themselves for this. It’s a massively dysfunctional system that costs the NHS money and damages continuity of care for patients who often have a new doctor every day of the week. Everyone is just following their own incentives, we can’t expect people to stay in unpleasant jobs when they have better options elsewhere. The root cause is poor pay and conditions, and we won’t fix things until this is addressed.
The collectivist solution of junior doctor strikes failed, locuming is the individualist solution. In any industrial action the employer’s case is ‘if you don’t like it, quit’. When walk outs failed doctors didn’t like it, so they quit.
