The views expressed in this document are those of the author, and are in no way to be taken as representative of the views of any other person or organisation involved in the storage or transmission of this document. This document is already in the Public Domain in the UK Professional Forum of Compuserve, and may be freely quoted and reproduced.
A personal (and probably biased) guide to how doctors in the UK are trained and work within the structure of the National Health Service.
As of 2003 likely to be increasingly inaccurate about current working conditions as a result of changes to doctors' contracts that do not affect the author and therefore of which he has no direct experience.
All currency figures in this document are in Pounds Sterling, so beware if your computer converts the Pound symbol: £ to a Dollar:$ .
First written August 1994
Minor Revision October 1995
Update of financial figures 1999
Expansion of New Deal section June 1999
Reaccreditation section September 2000
Minor tweaks August 2001
Salary info updated February 2002 (the NHS now publishes
current rates online, as does the
BMA)
If you are a doctor who qualified in another country, and you want to work in the UK, please DO NOT write to me asking for more information or personal guidance. You need to:
...the NHS Recruitment document, Being a Doctor in the NHS in England
For any other information, I suggest that overseas doctors should also consider contacting:
Overseas Doctors Association
316A Buxton Road
Great Moor
Stockport
SK2 7DD
Telephone +44 161 456 7828
Fax No. +44 161 482 4535
Please also read the Overseas Doctors' Handbook 1999
Another useful resource is the British Council Overseas Doctors Training Scheme (ODTS)
Everything I know is in this document. If the answer to your question isn't here, I don't know it. I do not offer individual career advice.
In 2003-2003 both the consultant body and the GPs entered into protracted negotiations with the DoH to completely re-write both their contracts and their systems of payment.
Much of what follows below may change radically when this contractual negotiation is concluded.
The education system in England and Wales is often spoken of as divided into Primary Education (5-12), Secondary Education (12-18) and Higher Education (18+). Education is compulsory by law for all children up until the age of 16, and there is a national exit exam at this stage, formerly known as 'O' Levels, now known as GCSEs (General Certificate of Secondary Education). The teaching curriculcum up to the age of 16 is laid down by the Department of Education in the National Curriculum, and this therefore closely determines the content and scope of education up to this point. Students who choose not to leave Secondary Education at age 16 after GCSEs, but instead continue to 18, will usually confine their studies to 3 or (occasionally) 4 subjects, in which they will have final exit examinations at the age of 18. These are known as 'A' Levels. The grades scored at A Level, and the nature of the subjects studied, determines and limits the choice of subject that may be studied in Higher Education (= University) and the quality of the institution where such study may be undertaken.
The education system in Scotland is similar as far as I know, except the names of the exams are different.
Medical Schools constitute one form of Higher Educational establishment, and there are about 30 Medical Schools in the UK. Most have an annual intake of around 100 new students, and the course usually lasts five years at the end of which there is a final exit exam ('Finals'). Entry to Medical School is normally made at the age of 18, following on immediately from 'A' Levels. However, all UK Medical Schools appear to accept a small number of mature students annually as part (5%?) of their intake. Students applying to study medicine require three or four high grade 'A' Level passes, and will usually have studied at least three out of Mathematics, Further Mathematics, Physics, Chemistry or Biology. Some Medical Schools run one year 'Pre-Medical' courses for students who have non-science based 'A'-Levels.
There is some variability in the length and approach of the training of doctors which is undertaken by different UK Medical Schools. The 'Classical' approach - still the commonest - is a five year course, broken into two distinct segments:
Two years of theory: Anatomy, Physiology, Biochemistry, Pharmacology, Pathology, Genetics, Sociology, Psychology, Bacteriology, Embryology.
One year of half-and-half theory (more Pathology) and early clinical experience, followed by one year of full time hospital-based experience, shadowing 'real' doctors, followed by the final year which is basically one long revision course.
....but the lack of early clinical experience, and the predominance of over-technical theory in the Pre-clinical phase has come under criticism. Some Medical Schools have adopted what they believe to be a more integrated course structure. Such integrated courses, for example, may expose students to direct dialogue with patients within their first week at medical school - even though their knowledge at that point of the patient's disease state or their treatment is close to zero.
Following qualification at medical school (= passing the finals exam), students may apply for a provisional registration and license to practice as a doctor in the UK. All such licenses are granted by the UK doctors' regulatory body, the General Medical Council (GMC). A provisional license entitles the holder to practice medicine only under supervision by a fully licensed practitioner. Full registration is obtained upon satisfactory completion of an approved, supervised apprenticeship of one year duration which must contain at least 4 months each of Hospital Medicine and Hospital Surgery.
Out of these regulations were born the 'Junior House Jobs', equivalent to the US internship. Although the stipulation is only for 4 months, in practice 99.9% of UK graduates undertake two 6 month contracts, one in Medicine and the other in Surgery. Accreditation for such posts towards full registration is granted by the local regional Medical School. Although clearly intended to oblige the new doctor to get a broad practical grounding in the bread and butter of medicine, the staffing requirements of the hospitals has historically forced considerable bending of this intent, so that it is entirely possible for a doctor to become fully registered having done six months of Neurology and six months of Neurosurgery, having never seen either an appendicitis or an asthma attack.
A Junior House Officer (JHO) typically works an average of 72 hours a week, based on a full 40 hour working week and cover for every 4th night and weekend. Such a regular rota results in a regularly repeating four week working cycle of 104, 56, 72 and 56 hours respectively with the longest continuous shift being 56 hours (9am Saturday until 5pm Monday).
Basic starting salary for a House Doctor is £18585 annually for the basic 40 hour week, but each post is then allocated to one of several pay bands depending on the amount of additional on-call duties worked and their intensity. Band supplements (as a proportion of basic salary) are then:
Band 1A– 50%, Band 1B– 40%, Band 1C– 20%
Band 2A– 80%, Band 2B– 52%
Band 3– 100%
Band FA– 25%, Band FB– 5%, Band FC– Pro-rata.
Thus, a House Doctor on a busy 1:5 rota may work an average of 26 additional hours each week, for which they receive an additional £14868 annually before deductions. Malpractice Insurance for this period is nil: the State pays any costs.
Following completion of the House Jobs, and acquisition of Full Registration, UK doctors may begin specialist training. In the initial phase, this involves seeking further six month contracts in appropriate specialities at the grade of Senior House Officer (SHO). Over a period of two to four years, a prospective specialist will change jobs (and frequently hospital) every six months so as to gain experience in and around their chosen subject. What counts as appropriate is determined semi-explicitly by the various Royal Colleges, who exercise responsibility for the Post-Registration training of all UK Doctors. During this period of time, it is common (well, effectively mandatory) to sit the relevant examination of the Royal College, since advancement to the next grade of training is virtually impossible without this. By the completion of the SHO phase, the doctor is usually 4 years out of Medical School.
SHO hours of duty are very similar to that of the JHO, and although they often have a JHO whom they supervise, they are often very much in the front line. Remuneration is calculated in exactly the same way, from a starting basic salary of £23190 rising to £ 30965 after 6 years. Additional duty hours (On-Call) are also calculated at 50% of the normal hourly rate. Malpractice insurance remains covered by the State.
In parallel with hospital training, doctors who aspire to become General Practitioners (Family Doctors) also undertake a period of hospital-based experience, working as SHOs for two years. The two years must include not less than six months in each of two of Medicine, Geriatrics, Accident and Emergency, Paediatrics, Psychiatry and Obstetrics & Gynaecology. The remaining year is commonly made up of another two from the list, although other options (e.g. Orthopaedics) are permitted. These posts are specifically accredited for General Practice training by the Royal College of General Practitioners, but in practice are virtually indistinguishable from speciality training posts. Many Hospitals, partly in order to solve recruitment difficulties and effort, offer GP training scheme contracts of two years duration at SHO grade during which time the doctor will work in a variety of specialities as required by the RCGP for accreditation. It is not obligatory to gain training accreditation by means of a hospital scheme; indeed approximately 30% of doctors who gain GP accreditation do so via a 'DIY' scheme. Terms and Conditions of Service, hours of work, remuneration and Malpractice arrangements are as for speciality training SHOs.
Following the proscribed hospital two years, Vocational Trainees for General Practice undertake a year working in an approved General Practice Partnership under the guidance and instruction of an approved GP Trainer. During this time, the Trainee gradually gains in experience until working with the same freedom and responsibilities towards the patients as the Partners. The Trainee year is characterised by compulsory attendance at a weekly full day-release vocational training course, during which topics as diverse as Practice Finance, Man Management, Transactional Analysis and Group Dynamics might be taught. Therapeutics and more clinical skills are often left to the recommended additional 3 hours a week dedicated one-on-one teaching with the Trainer. Malpractice insurance is arranged privately by the individual Trainee, current cost is approximately £1100 annually. Working hours are probably about 72 hours a week. Remuneration is less than for hospitals, being 122% of the basic salary for an SHO of the same seniority (the 15% is a flat rate payment for all On-Call) and a further £3928 for the Car expenses.
At the end of the Trainee year, it is common to take the examination of the Royal College of General Practitioners by way of an exit examination. This is not a necessary requirement (yet) of acquiring full accreditation for completion of GP training. Having completed this training vocationally trained GPs are free to apply for posts as a Partner in General Practice whenever and wherever the vacancies appear. Malpractice Insurance remains the responsibility of the individual GP, and costs upwards of £1500 annually (I think...)
Individual General Practitioners in the UK currently have, on average, about 1800 patients registered under their care. They almost universally work within a business structure, being contracted by the State to provide certain core medical services for the patients on their list. A typical GPs day usually takes the form of a 2-3 hour surgery in the morning, and another in the afternoon. These surgeries may be by appointment, or open access at the GPs choosing. On average, each patient spends between 5 and 8 minutes with the GP at each such consultation. After morning surgery, UK GPs usually perform home visits, to which patients no longer have an absolute right but which remain the only practical way to deliver healthcare to many of the old and immobile. On average, there are around four of these, per GP, per day.
Following home visits most GPs now run special clinics of one form or another during the afternoon: diabetic, hypertensive, child surveillance, ante natal clinics and so on. The core service also includes an obligation to provide 24 hour, 7 days a week, 365 days a year emergency medical services, at the patient's home should they so require ( 2003 contract will change this) . GPs may delegate some or all of this 'OnCall' commitment to colleagues, or deputies, but remain ultimately medico-legally responsible for the actions of their stand-in. On average, a GP works around 70 hours a week in 1995. Malpractice Insurance remains the responsibility of the individual GP, and costs £2165 in 1999.
Remuneration of GPs is complex ( 2003 contract will change this). General Practitioners, as they did before the NHS, generally work in partnerships of some 3-5 doctors. The greater part of a partnership's income now derives from fulfilment of their NHS contract. The bulk of the income comes from multiplying the total number of patients cared for by a fee per patient (known as the capitation fee):
Capitation Fees (March 1999 figures):
...and then adding on the Basic Practice Allowance which is linked to the absolute number of patients:
Basic Practice Allowance (March 1999 Figures)
Capitation fees and Basic Practice Allowance alone would give a GP with a typical age:sex mix and list size an income of around £66,280 gross a year. In addition to this income, however, almost all practices elect to provide a range of optional additional services (not compulsory under the contract) for which there are additional payments available from the state on a fee-per-item basis. For example, some of the more common 'extras' and the payment GPs received in March 1999 for each patient so treated:
There are also a number of Health Promotion activities for which GPs receive payments provided they reach various uptake targets in their population:
...and then there are deprivation payments, if your practice area is considered to be particularly poor (and the morbidity consequently higher), Rural Practice Allowances (to cover the additional costs of driving around remote areas), Seniority Payments etc. etc. etc. This baroque arrangement requires much chasing of paper, and permanent uncertainty regarding your final income. A significant number of GPs intermittently question whether it would be simpler to become a salaried service, directly employed (rather than contracted) by the State in the same way as Consultants. Opponents of this idea say that it would prevent keen, dynamic GPs from being able to increase their individual incomes through hard work.
From this grand total of income from all sources, the expenditure of the practice such as on buildings and staff must first be deducted, and the remainder is income for the Partners. GPs can also earn additional money through private, i.e. non-government, medical work (e.g. Occupational Health for a local Industrial Employer, medicals for insurance companies). Some practices share equally the pooled private incomes of all the partners, whereas in other practices the individual partners retain whatever they earn in addition to NHS income.
This payment scheme suggests that the more work GPs do, the more they earn over and above the capitation fee payment. Whilst this is broadly true for an individual practice, it is not true for the combined income of all GPs - the total amount earned annually by all GPs in the NHS. This is because the money paid out each year - both for honouring the contract and as fees for all the optional sections - actually comes out of one big, but finite, pot of money. The size of this pot is calculated precisely in advance, on an annual basis, by choosing a sum of money which is considered an appropriate annual income for an average GP in the coming year. This 'average gross intended remuneration' figure is then multiplied by the number of GPs in the country to arrive at the total budget for GP services which the Government expects to pay during the following year. All the various fees - capitation, basic practice allowance, item of service fees etc. - are then reverse-engineered from this sum.
The 1999 figure for average gross intended remuneration stands at £75,892. This figure often appears in the popular press as evidence that GPs are fabulously well paid, considering they spend all day on the golf course. Of course, this gross figure is before the GP has paid any of their staff.
In 1999 The Department of Health reckoned that it costs £24,700 per GP in a practice to cover the practice expenses, a figure calculated by the DoH randomly selecting a small group of 'typical' practices annually and, from their accounts, calculating an average expenditure. Thus the total practice income, before expenses, should be the number of GPs multiplied by £84474. After the expenses are met, however, the Government intends each GP to take home an average net intended remuneration of £61218 on which the GP subsequently pays income tax and so forth (currently about 30%).
A digest of the 1992-1993 workload survey of General Practitioners, an annual study used as part of the process of deciding centrally what GPs should be paid, is here.
A seemingly minor change to the GP contract that pre-dated the larger 2003 complete re-negotiation was that GPs are no longer medicolegally responsible for the actions of a deputy whom they appoint: the deputy is responsible for themselves. A consequence of this is that GPs are less concerned about whether they are in legal partnership with all the doctors who look after their patients. The legal change, coupled with the new trend for new doctors to delay applying for partnerships, has led to a rapid rise in the number of practices who are willing to recruit salaried GPs.
These doctors are employees of the proper partners in the same way that the practice nurse is. Because they are not partners they have no financial stake in the building or right to make or influence partnership business decisions, and they have no non-clinical duties such as being responsible for equiping the practice, repairing the building, hiring and firing receptionists, negotiating with the NHS etc etc.
In recognition of the fact that these salaried GPs only do the clinical work and not the administrative work, they are currently paid less than a full partner. However, because demand for them exceeds supply the reality is that they aren't paid that much less: currently (Feb 2003) posts are advertised at around £55000 per year.
The GP labour market at the time of writing is therefore rather uncertain and, because contract negotiations are in progress, it is difficult to separate lobying from the truth in what is reported. The BMA points out that the number of posts still vacant after 3 months is rising, and anecdotally there is evidence that it is increasingly difficult to recruit partners. The NHS for its part has recognised that there is some kind of recruitment crisis through the introduction of various golden hello, golden handcuff and pat-on-the back financial reward schemes.
Meanwhile, the status of Primary Care Partnerships as independent fiefdoms is also under change through the introduction of Primary Care Trusts. These are groupings of several practices- typically 10 or 15 (thus approx 30-40 GPs) under the auspices of a single administrative body that seeks to provide some overarching locally informed policy. PCT boards are predominantly made up of GPs, but have a sizeable representation from other helathcare professional and lay groups in the local community (who often feel that progress is being stifled by the GP stranglehold on the board).
Originally the raison d'etre of PCTs was to take a larger-scale view of local health needs and health purchasing requirements than was the case with practice based fundholding. However, they are starting to widen their role. Some are employing salaried GPs directly. For example they may employ a female GP who then works one day a week in 5 different single-handed practices where there is only a male partner and therefore no choice for female patients. PCTs are also beginning to attempt to get a grip on the information that would help them manage, namely the practice computer systems. Some PCTs are trying to change all their practices over to a common system. A few are going further and centralising the physical computing and data warehousing facilities.
The posts of Registrar, Senior Registrar and the new unified Specialist Registrar grade make up the middle grade hospital medical staff.
Entry to the middle grades of Junior Hospital Doctor is now regulated by a strict quota system. It was recognised in the early 1970s that the medical career ladder had a significant bottle neck developing in it such that, without action, there would soon be large numbers of doctors who had completed their specialist training, but for whom Consultant Posts did not exist. It was felt that this would be detrimental to the morale of the profession and the well being of the public (see the Snow report). As a result, a committee named JPAC sits annually to decide on exactly how many Registrar and Senior Registrars there will be that year nationally in each of the various specialities. Thus, all Registrars and Senior Registrars are assigned a number, and no further middle grade appointments may be made unless a number becomes free (unless the doctor is from overseas, and not intending to settle in the UK).
In theory, this quota system was supposed to control matters while a 2% compound annual increase in Consultant numbers gradually relieved the need for it. It is a matter of considerable debate as to whether this expansion has taken place, and whether JPAC has done its job properly. Cynical Juniors argue that it is not in the Consultants' interest to expand Consultant numbers as this increases competition for their Private Practice Income, nor is it in their interest to decrease the numbers of Juniors, who do all the NHS work on behalf of the Consultants when they are busy in their Private Practice.
Middle Grade posts are usually of three year tenure, although there is commonly rotation between firms and sub-specialities within and between hospitals during this time. Further Royal College Examinations - usually of a more clinical bent than previously - are undertaken during this time. Because of the persistence of the bottle-neck, it is also becoming common (verging again on obligatory) to undertake some form of research work as a Registrar in order to further your chances of succeeding in an application for a Senior Registrar post.
Registrar and Senior Registrar hours of duty are notionally also no more than an average 72 hour week, but since there are relatively fewer of them it is probable that many are still on 83 hours or more. Most, if not all, are shielded from the front line of duty by virtue of having an SHO and/or a JHO working beneath them. Some of them even get to sleep!. Basic remuneration for these posts is £25920 rising annually to a maximum of £ 37775 after 9 years. The pay banding system applies as before, although generally SpR posts are in less lucrative pay bands as they get more sleep. Malpractice Insurance is still covered by the State.
The average age of appointment is probably about 32 overall, tending to be somewhat higher in the Surgical Specialities. Most Consultants contract part-time with the NHS in order to build and maintain a Private Practice in addition; typically they work for the NHS three and a half days a week, and spend the rest of the time in Private Practice. Private diagnostic or Inpatient services are generally provided by commercial hospitals, run by organisations such as BUPA or AMH.
NHS salaries for Consultants commence at £52640 rising to £68505 after five years, but with the potential to increase to £90465 after thirteen years if the management feel you're worth it. Consultants on part time salaries will earn proportionately less from NHS work. The State provides malpractice cover arising out of any work performed on the NHS, but the Consultant must make separate arrangements for any claims arising out of Private Practice.
The traditional career ladder of PRHO to SHO to SpR to Consultant is taken by the majority of doctors. However, a few fall by the wayside for various reasons and don't quite make the grade. The cuddly NHS, not wanting to lose these people, therefore from time to time creates new long term contract career grade posts for such doctors who are stuck on the career ladder, can't progress further up, and would have the next generation of doctors snapping at their heels if they were obliged to keep applying for the typical short-term 6 month junior doc post.
The BMA tends towards suspicion of these posts, noting for example that many Associate Specialists end up with full consultant responsibilities but for less pay and therefore worrying that the NHS is abusing these posts as a means to get cheap labour. Whilst they accept the argument that a place is needed for those doctors who fall off the career ladder, they keep a weather eye on the number of such posts created and filled. After all, there can't be that many stuck doctors and, if there are, maybe it reflects problems in the NHS's own training arrangements and support.
Associate Specialist is therefore the official title for the post occupied by somebody who couldn't quite make it to consultant, whilst Staff Grade used to be the term for somebody who couldn't make it to SpR.
Fairly early on in the history of the NHS it was recognised that the position of the government as effectively a monopoly employer made pay bargaining somewhat tricky, and potentially unfair. A similar problem was identified for other professions, such as Nurses and Teachers. In order to avoid any unseemly rows between gentlemen, the government instituted a system of independent pay review bodies. The idea was that, on an annual basis, the government and doctors would put to a panel of independent reviewers their views as to what doctors should be paid. It was expected that, more often than not, both sides would usually, as gentlemen do, suggest more or less identical pay levels. Only when a minor disagreement arose, say every decade or so, would the Review Body have to actually do any arbitrating. Whatever figure was agreed would be universally binding to all state hospitals.
The reality has been rather different. The Pay Review bodies for medical and dental practitioners have never received 'Joint' (i.e. concordant) evidence, and in some years have actually had to arbitrate more than once. The government, especially in recent years, has often overruled the arbitrated decision, or agreed to fund half of a recommended increase centrally, insisting that the rest of the pay increase be met locally by individual hospitals making savings from their service provision.
Needless to say, neither side are particularly happy with the way things have turned out. However, the profession seems even less thrilled at the direction the government seems to be taking now: Trust hospitals will soon acquire the right to ignore any centrally agreed pay scales, and will begin local pay bargaining. This is a move the government supports, and wants to take even further with pay settlements both nationally and locally having an element of performance related pay built into them.
In 2002-2003 the BMA and the DoH entered into negotiations to completely re-write both the GP contract, and the contract for NHS consultants. However, at a vote, 60% of the consultants rejected the best offer that their negotiators could come up with. At the time of writing the GP contract shape has been published (but failed to impress many) but final judgement and voting is pending because the NHS hasn't yet disclosed what they are willing to pay GPs if they accept it.
The description above attempts to give an overview of the various training requirements for doctors working in the UK. The mechanisms to ensure appropriate experience and training are gained also presuppose appropriate supervision at all stages. Whilst there has always been an understanding that complete, unbroken supervision of junior doctors by more senior ones was unrealistic, in recent years it is widely felt that raw quantity of (often unsupervised) experience has been relied on too heavily as a substitute for quality. Consultants, nominally the supervisors of the continuing education of the Junior and Middle Grade Staff on their firm, have always been obliged to balance the pressures to maintain the service against the expenditure of time in training activities. As hospitals have become more intensive places to work, the balance in the eyes of many in the training grades has tipped increasingly against supervision and quality of experience. The demands for improved patient throughput on reduced budget that have arisen with the NHS reforms have only served to strengthen these pressures.
It will also be clear from the above account that the hours worked by UK doctors 'at the coal face' are long compared to European standards, especially when the length of time in training before gaining Consultant status is considered. In fact, the current figure of 72 hours quoted above is low compared with less than ten years ago. In 1990, UK Junior Doctors were by and large working an average of between 83 and 90 hours a week, with some working as high as an average weekly committment of 104 hours (a 1 in 2 rota).
Further, the average weekly figures of yesteryear and of today hide the fact that in individual weeks a doctor will do more than the average - particularly when one or more of their colleagues on the duty rota is on holiday or sick, and they therefore must take on the absent doctor's day-time and night time duties as well as their own. 'Prospective cover' - the contractual requirement to cover such absences - has the effect of turning a 1:4 rota into a 1:3 much of the time because there is rarely a week when one of the 4 people sharing the rota is not away on holiday or study leave. In 1991, as a result of the concurrent absence of two colleagues (one on holiday, one sitting exams), I personally did a single continuous 5 day shift of 104 hours without break resident in a hospital, being simultaneously first On-Call for Orthopaedic, Trauma and Otorhinolaryngology emergency referrals for a population of 250,000 via the local ER or direct telephone referral by GPs. This single shift was as part of a week when I was present, awake and on duty in the hospital for a grand total of 136 hours in 8 days.
Payment for 'overtime' - all work done for any reason outside 9-5 office hours - was precisely zero until 1976, when a Juniors' Strike resulted in a reluctant government instituting Additional Duty Hours (ADHs). These provided a prorated payment in addition to the full basic salary, and the additional payment was calculated as the average number of extra hours worked each week (over and above the basic 40) multiplied by an hourly rate. The only catch was that the hourly 'overtime' rate was fixed at 30% of the presumed full hourly rate that applied during office hours (NOT 130%). This overtime rate therefore amounted to slightly less than the standard daytime rate for porters in the same hospital.
For many years the senior element of the profession resisted calling these night-time and weekend duties 'overtime'. It was considered 'part of the job', 'good experience' and doing it for nothing or peanuts was what distinguished the noble medical profession from other, lesser employment. In their day, of course, the radiopager had not been invented and extracting a Junior from his bed involved a porter being sent to his room. Fearsome Matrons patrolled the wards and, to a large extent, prevented less experienced nursing staff from irritating the dormant doctor needlessly. Medical Science itself was simpler and there was a great deal of difference between what was possible during office hours and what was possible at any other time. For example, the amount you could or should realistically do in 1950 for a new admission of Chest Pain in the middle of the night was considerably less than today. My father recalls that obtaining even an ECG was a day's march, requiring the patient to sit in a darkened room while an oscillating needle projected a shadow onto a moving strip of photographic paper which, when developed, became the ECG strip.
Whilst on duty, but not on the wards, our medical forefathers had a relatively pleasant time of it: most hospitals still have a Junior Doctors' Mess where on-call doctors may rest in worn-out arm chairs and watch a TV paid for from deductions out of their own pay packet, but few still have the doctors' dining hall where hot breakfasts and meals were available on request at all hours. These have all been closed because they were not economic - after all, only the doctors ever ate in them. The nursing staff, increasingly, waited to eat once they were able to go home at the end of an 8 hour shift. Similar economic reasoning is used to explain why Junior Doctors must pay to park their car within the hospital grounds (even when on call).
Accomodation in hospitals has deteriorated similarly. Most contracts for Junior Doctors are only for 6 months, so a doctor may regularly move a great distance to find the next post to further their training. Traditionally, to make these transitions smooth, accomodation has been available at each hospital on request. Part of the employment 'package' of medicine of yesteryear was that the long hours of a Junior were compensated for by the fact that the hospital fed them and provided a roof over their head. Today - even when on a 1 in 2 rota and therefore obliged to be present and sleeping in the hospital every other day - a doctor will still be offered a room or flat within the hospital as a permanent place of residence for the duration of their contract, but they will have to pay rent for that proportion of the week when they are not actually on-call. Those doctors that choose not to keep a permanent room at the hospital can share a single on-call room so that, if they were lucky enough to have a break to sleep in whilst on duty, they had somewhere to go. It was not, however, uncommon to find - when you eventually got to the room at 4am - that the sheets had not been changed since the last occupant.
A further significant but unremarked passing has been the Doctor's Bar, whose remnants usually still sit in one corner of the Doctors' Mess. Several consultants have admitted to me that, when a Junior, it was not unusual for them to have one (or two) beers from the bar whilst on duty and therefore that they were not always entirely sober whilst admitting patients. The lifestyle of doctors portrayed in 'Doctor in the House' is almost certainly a charicature of the reality of the 50s, but probably also contains a grain of truth. It is unrecogniseable to modern Juniors, except that Sir Lancelot Spratt is (of course) alive and well.
In response to a growing sense of injustice and outrage in the Juniors' Ranks, (and rumoured to have not a little to do with the fact that the Health Minister's daughter had begun to study medicine), the Government struck a deal in 1991 with the profession to reduce working hours to a contractual maximum average of 72 hours a week on-call by the end of 1994 with the added proviso that work intensity when on-call should be such that a doctor should only be expected to be actually on their feet and working for 56 hours a week on average. Jobs with high-intensity workload, therefore, should adjust their on-call rota accordingly or consider moving to a full shift.
As an additional measure (or sop to the disaffected workforce) the On-Call ADH payment was simultaneously increased from 30% to 50% for a rota, and from 30% to 100% for those working on a full shift pattern. This package was billed as 'The New Deal' for Junior Medical staff. It was supposed to address all the Juniors' woes - including standards of hospital accomodation and availability of food - but it ended up focussing almost entirely on the number of hours worked.
The principal methodology for achieving the hours reductions was to encourage hospitals to deploy their junior medical staff in new ways. Instead of the traditional 40 hour, 9-5 week with additional nights and weekends on call, it was envisaged that large numbers of doctors should move to working either full shifts, or partial shifts. An idealised partial shift entailed working normal, or slightly extended, working days for a few weeks than swapping to the night duty only for an entire week.
An additional measure was to increase the expansion in consultant numbers, with the apparent (although always unstated) aim of encouraging a move to a consultant-led service. But simple mathematical calculations suggested that, if the juniors were no longer permitted to work so many hours as previously, and no new additional junior posts were going to be created, then there was likely to be a shortfall in the number of hands available to actually run the hospital. The consultant body quickly began to complain that if anybody thought that they were going to be running the show at 4am, then you could think again.
Since the ratification of the New Deal in 1991, the overall recorded hours worked by Junior Doctors have dropped from an average of well above 83 to slightly below it. However, much of this drop occurred within the first 12 months of the initial 3 year New Deal plan and very little has changed since. There is considerable belief, and some evidence, that much of even this early apparent improvement arose as a result of massaging of the figures on paper.
Reasons for the final failure are legion, including limited enthusiasm for the implications from the consultant body, very limited enthusiasm from the Juniors for the proposed shift work patterns, complete resistance on the part of the government to pricing long hours prohibitively, and probably the most fundamental reason: the numbers simply didn't add up. Meanwhile, the nurses - who it was hoped might take on some of the more pointless nighttime duties of Juniors (such as siting intravenous lines) and so help make on-call more bearable if not actually shorter - refused outright to get involved, saying that they didn't see why they should have to help the doctors get their own house in order. Unless, of course, these new duties were accompanied by a pay rise.
Right from the outset, therefore, many observers characterised 'The New Deal' as no carrot and no stick. Its most fundamental weakness, however, was that there were too few donkeys. There were not then - and there are not now - enough trained doctors in the UK to take up the slack if Junior Doctors reduced their hours by the amount proposed. No significant reduction in the workload of Juniors can ever be achieved without either redistributing their workload to entirely different professional groups or increasing the number of doctors trained each year. Whilst increasing medical school intake is within the power of the politicians (and was announced as part of the NHS Plan package in 2000), it still takes 10 years to train a doctor. Therefore any serious plan to reduce hours must wait a decade before the necessary human resources exist to finally put the plan into practice. Unfortunately for today's Juniors the New Deal did not include any Medical School intake expansion, so the staffing problem is as bad today as it was then.
To date (Febraury 2003), therefore, it comes as no surprise to learn that the stated goals have not been reached, or that in May 1999 the government stated that it would not be able to meet the final The New Deal target of 56 hours for at least another 7 years (12 years later than promised) and would not be able to meet the new EC working time directive of a maximum 48 hours working week for at least 13 years. In fact the general EC Working Time Directive currently specifically excludes doctors in training. Instead the directive requires that doctors in training should work no more than 58 hours by 2004, 52 by 2009, with the 48 hours enjoyed by everybody else being a long term target. Note that any employee can choose to sign a document saying that they wave their rights under the directive.
Meanwhile, Junior Medical Staff continue to work long hours, often being contracted for hours within (some) of the New Deal targets, but actually being required to work longer either without additional pay or being obliged to claim the time as overtime so that it doesn't show up on the official job description.
Meanwhile, discontent in the ranks moved focus somewhat from the insoluble hours problem to the issue of the training structure itself: if we really have to work all these hours, do we really have to do it for quite so many years before we can apply for a consultant post?
In 1993 a number of political events came together:
These events led to the setting up of a full scale review of UK training practices and structures, chaired by the Chief Medical Officer, Dr Calman. The report of this committee (known as The Calman Report) recommended radical changes to the UK training structure, which would result in (amongst other things) a shortening of the overall required training program prior to full accreditation, and amalgamation of the middle grade training grades (Registrar and Senior Registrar) into one (Specialist Registrar). Most of the recommendations were adopted, with the combined training grade being adopted from April 1996 for all Hospital Specialities. It is too early to say how successful these changes will be.
In May 1999, however, the agenda returned to the hours issue. With the BMA reporting that at least 1 in 3 Juniors still worked hours outside The New Deal limits - indeed, that the number working outside the limits in 1998 was higher than for the previous year - the Junior Doctors' Committee balloted its membership to find out their willingness to take industrial action. They were presented with choices beginning with 'working to rule' and progressing to withdrawal of labour. 90% of those that responded said they would be prepared to take some form of action. However, the response rate was only 30%. Despite this poor mandate for action the Health Secretary (Frank Dobson) offered to open discussions on rates of pay, which resulted in the pay banding system already detailed.
The legally enforceable limit of 58 hours under the European Working Time Directive comes into effect in 2004, and is likely to drive significant radical change in both typical working patterns and responsibiltiies whilst at work. These include most juniors now working on shifts (which were advocated under the 1991 New Deal, but never popular) and also juniors providing cross-specialty cover during on-call hours, e.g. one junior covering both medicine and surgery rather than one or the other in isolation.
Meanwhile the Consultants negotiating body has also begun to complain about differences in hours of work. The more hard-pressed consultants (e.g. Anaesthetists) have noticed that they are spending considerably more time at the real clinical coal face after hours than, for example, their colleagues in Dermatology. Given this increasing difference they are questioning the fairness and appropriateness of the traditional NHS pay scale that pays Consultants at the same rate, regardless of speciality.
Events in 1999/2000 focussed political and public attention on the question of who regulates and monitors the doctors. The statutory regulatory body, the General Medical Council, came under considerable criticism and was accused of protecting doctors at the expense of patients. Several high profile cases of badly performing doctors raised serious concerns:
In Bristol, two paediatric cardiac surgeons were struck off the medical register after it emerged that mortality from their operations was approximately double what would be expected. Approximately 30-35 babies are believed to have sufffered avoidable death; many more suffered substandard care and had substandard outcomes. Even though this had been known to the surgeons concerned for some time they continued to operate and were allowed to continue. The whistle was eventually blown in public by an anaesthetist at the hospital. An additional worrying aspect of the case was that his initial efforts to raise the matter internally and locally with regional heads of surgery and anaesthesia had met with considerable pressure to keep quiet. A public report into the case was published in July 2001. Amongst many observations was the fact that the doctors concerned, and the senior nursing staff, colluded in creating a club culture of fear that prevented the concerns of more junior staff either coming to light or being acted upon.
Harold Shipman was a single handed GP in Manchester who personally killed by lethal injection approximately 230 women of various ages for no obvious personal material gain. 3 patients died while in his surgery. His standardised mortality rates were statistically well above average and the anomaly could have been detected much earlier, if anybody had been bothered to look.
Rodney Ledward styled himself as the fastest gynaecologist in the South. His operative technique damaged hundreds of women - approximately 400 came forward - but he was not struck off by the GMC until September 1998, long after the details of his case were publically known. A report (The Ritchie Report) was commissioned to examine why the problem had gone undetected or unaddressed for so long, and this reported in June 2000. One of its key findings was that staff who might have voiced or who did voice concern had been intimidated by his consultant status. The Secretary of State for Health (Alan Milburn) promised to end the 'Consultant is King' culture. The BMA retorted that the days where Consultants chose to behave like gods were long gone. Sir Lancelot Sprat was unavailable for comment, but was believed to be still working in any number of teaching hospitals around the country (see Bristol, above).
Richard Neale was another UK-originate Gynaecologist who was struck off the Canadian medical register in 1985 following the deaths of two patients. He subsequently returned to the UK, where he was then allowed to practise normally as a Gynaecologist despite his Canadian judgement. In 1995 he was given a large sum of money and a clean employment reference to leave the hospital where he had been working for the previous 10 years, after concerns were raised internally about his performance. The hospital did not raise their concerns with the GMC at that time. Only in 2000 did he eventually appear before the GMC, charged with 35 counts of clincal incompetence, following which he was struck off the UK medical register.
Following the Bristol case the GMC began to accelerate its proposals for reaccreditation of doctors, however by June 2000 it was clear that their proposals were not percieved as sufficient and in any case were not being implemented fast enough. There are proposals for an annual reaccreditation system to be set up within the NHS as an employer, and outside the direct control of the GMC. Meanwhile the medical press has been openly voicing concerns that the GMC is clearly failing to protect either patients or the reputation of doctors as a profession. The GMC has responded by decreasing the size of its governing committee from an unwieldy 130 members to a slimline 35, opening a new disciplinary hearings tribunal office in Manchester, and tripling the annual cost to doctors of being on the register.
February 11th 2003
Dr Jeremy Rogers MBChB (Manc), MRCGP, DRCOG, DFFP, GP(T)
jeremy@cs.man.ac.uk