A survey of over 2,000 family doctors working in England has indicated a sharp fall in working hours post-pandemic, with more and more GPs switching to part-time status. Some 58.4% of respondents are working six half-day sessions or less. These reduced hours are one of the reasons it is so difficult to access a GP, why you rarely see the same one twice, and why A&E departments in hospitals are so overstretched, with desperate patients who can’t get an appointment with their local practice forced to turn elsewhere.
Some unkind comments have focused on the fact that two thirds of GPs are women, who are far more likely to work part-time than men. But that’s a choice, and one which in the 21st century we cannot deny doctors. Nor can we prevent an increasing proportion of GPs from retiring early, as seems from this and other surveys to be their intention.
However these trends do point once again to the problems involved in the way in which the medical labour market, dominated by the NHS, operates.
We attempt to ‘plan’ the supply of doctors. Although the sort of human resource (formerly known as ‘manpower’) planning which was common in the 1960s has vanished from the bulk of the jobs market, medical school places are fixed by the government every year on the basis of projected demand for doctors 10 or 20 years down the road.
Inevitably the assumptions made are largely guesswork in our rapidly changing society. We may have some rough idea of the number of likely patients with particular diseases, but that can alter as lifestyles, medication and other therapies change. And predicting how many doctors will want to work as GPs, how many will want to work full-time, how many will leave the profession, how many will retire early, is just as difficult to anticipate.
The British Medical Association and other pressure groups resist changes to the current planning arrangements, pointing to the considerable cost of training a doctor – currently about a quarter of a million pounds – and the risk of ‘over-supply’, which might force down doctors’ rather generous salaries.
So we have very detailed central planning of university recruitment (something we currently have for no other area of higher education). Looking at the Office for Students site, we see, for example, that this September the University of East Anglia can recruit 208 student medics, Keele 164, Lancaster 129 and so on.
The hope is always that the planners have guessed right and the supply of new doctors matches the demand a few years down the road.
But they never do. We have got into a rut over many years where we get this wrong, and have shortages of doctors (and dentists, whose numbers are similarly fixed). The result is that we can’t get to see GPs and have massive waiting lists for many medical procedures.
The traditional fix to fill the gap is through recruiting doctors from abroad. Now, in modest numbers, foreign-trained doctors add to the variety of NHS experience and make a useful contribution to a two-way international exchange of good practice. When we look at numbers coming from countries such as Australia or Canada or Germany we can point to many British-trained doctors going in the opposite direction. But this is not the case for the majority of overseas-trained doctors, who come from countries far poorer than ours. Few British doctors move to India or Nigeria, two of the largest suppliers of NHS medics. The real reason that the NHS uses so many foreign doctors is that we avoid their training costs.
This trend has accelerated in recent years. Already over 30% of doctors are foreign-trained, and in 2019 over half of all those joining the GMC register were international graduates. Foreign-trained doctors tend to concentrate in large cities, which produces further distortions.
We could, of course, allow this to continue indefinitely. We have got used to many of our goods and services being produced by cheaper overseas labour. But British medical training is still of a high quality, and patients would probably welcome a higher proportion of UK-trained staff. We ought to let our universities use their expertise to produce a higher number of doctors (who will, of course, include many born overseas). Rigid central planning of numbers needs to be relaxed. The Medical Schools Council suggests that UK universities – which regularly have to reject young people with good A level qualifications – could expand their intake from 9,000 a year (It was till recently only 7,500) to 14,500 a year without risk of poorer quality or over-supply.
Central planning of entry numbers is not the only peculiarity of the union-dominated medical labour market in the UK. There is also control of pay, with detailed national pay scales for employees and contracts for GPs. Little regional variation is possible (although Scotland, where the NHS is devolved, pays slightly more than England), despite the existence of big regional variations in doctor shortages. Vacancies in London and the East of England are nearly twice those in the North East and Yorkshire, but employers can’t vary pay sufficiently to address this.
The NHS has many problems and badly needs to reform. In thinking through organisational changes, training, recruiting and rewarding doctors has got to be a key feature. The largest employer in Europe needs to be more flexible and responsive.
This article was first published on the Institute of Economic Affairs blog.
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