David Oliver: Shortening and narrowing training won’t solve the medical workforce crisis

We’re still yet to see the long promised NHS workforce plan for England1 or any equivalent in the devolved nations. Nevertheless, many proposals have been leaked piecemeal to the media, and various commentators on the political right are floating their own half baked ideas to tackle the issue.

NHS England’s proposal for apprentice doctors trained in an “earn while you learn” model—albeit with conventional medical schools still overseeing final exams—has been heavily trailed.2 It raises questions around logistics, equivalence, feasibility, and the burden on supervising senior doctors. But given the government’s edict to medical schools in 2022 to cap student places34 at 7500 when the original expansion plan had been for 10 000 and the workforce plan may pledge 15 000,5 it seems clear that government spending is a major driver despite talk of using “doctor apprenticeships”6 to diversify entry to medical training. And last week headlines centred on proposals to send specialty and associate specialist (SAS) doctors to work in general practice regardless of their training, experience, or qualifications in primary care.7

I don’t believe that the right solution to the UK’s doctor shortage is to reduce the length, breadth, and rigour of training. Nor to reduce the qualifications required to provide care. Nor to substitute doctors’ roles with other staff groups whose own skills and training are also valued but are not a like-for-like substitute for the broad, serially examined and assessed undergraduate and postgraduate training of doctors. Since I was at medical school in the 1980s some things have increased vastly, including the range and volume of medical evidence, treatments, and investigations, and the complexity of the patients we care for. The notion that we could condense the required undergraduate training into three years and produce equally rounded graduates seems bizarre.

The same applies to postgraduate training. Across adult medical specialties our case mix is increasingly patients with multiple long term conditions, treatment priorities, and medicines, often compounded by ageing or frailty. Even the single organ specialist or proceduralist will increasingly require a good generalist background to be the named consultant for the whole patient stay (and patients do value continuity), or they’ll have to refer them for every problem encountered outside their narrow field.

More than ever, we also need confident expert generalists in secondary or primary care, which in turn requires broader experience and exposure to a range of conditions and disciplines—not less. The primary care proposals seem deeply insulting to the idea of general practice as a skilled expert specialty in its own right, not something that any doctor can just slot into. Besides which, many doctors take some years after qualification to settle on their preferred field. There are exceptions: some people leave medical school already clear on a career path and keen to specialise early. But the number of foundation doctors taking time out of training programmes to give themselves some decision making space and wider experience speaks volumes.8

I have great respect for advanced care practitioners and physician associates, and they are valuable colleagues—but their training, qualifications, and roles are not interchangeable with more broadly trained senior doctors. They have different jobs with different skills. What’s more, all NHS clinical professions face a workforce crisis of their own.9 There’s no magic reserve supply anywhere.

What would I like to see instead of all this? Fund the expansion of UK medical schools properly. Scrap repayment of medical school debt for anyone who continues to work in the NHS after foundation years. Improve terms and working conditions so that we retain more qualified doctors at all stages of their career. And we need a similar and parallel plan for nurses and allied health professions, along with continued use of international graduates within an ethical framework.

The people behind the reform proposals are often hostile to the professional power and status of medics—partly because of the duration of our training and the difficulty required to attain our qualifications—and are reluctant to put more money into training or retention. And, in many cases, they’re hostile to the NHS itself.