The BMA being irresponsible in failing to raise issues other than pay. (Sorry another Doctor one.)

[Needmoresleep]

50% of those who finished their second Foundation year in the NHS last August were unemployed. Some have managed to stitch together enough locum work to pay the rent, but a good proportion have had to look further afield, especially Australia.

Unemployment numbers have been growing. It is not just about training. Very few ever got onto training directly from F2. Some might need more time to think about what speciality they want to go into. Some need more time to prepare their application, or to reapply. Others don't want the long slog of more exams and endlessly moving around the country, and are content with a Locally Employed Trust job and the SAS career route.

Unfortunately local and Clinical Fellow jobs are listed as skill shortage jobs and open to applications from across the world. Vacancies routinely attract several hundreds, if not thousands, of applicants. Newly qualified doctors finishing Foundation cannot compete with experienced doctors from overseas, willing to take entry level jobs because: the pay is higher in their home countries; they hope they will be able to get onto training; or they are attracted by the offer of relatively fast family settlement. Also jobs come up through the year whereas all F2s finish in August. A UK F2, working long hours and strange shifts, might need to complete hundreds of applications before they even get an interview, and that would probably be a job far from where they would like to live and away from a speciality they would like to work in.

In short a huge army of unemployed and under employed doctors has built up. Both UK medical graduates (UKMGs) who have failed to establish themselves on the bottom step of the rung, and International Medical graduates (IMGs) who have come to the end of a fixed term contract. (This type of entry level job is often fixed term.) There is no resident priority, so both groups are struggling whilst the NHS continue to bring in doctors from overseas. .

Hence the pay erosion. If you can employ experienced doctors into entry level posts you start increasing the number of jobs at that level. (I don't have a medical background and so don't have access to figures. However I read that this is happening, and it is certainly confirmed by DDs observation/experience.)

Unless the basic problem is fixed, ie restoring resident priority, the problem will continue to get worse. More pay will simply increase the number of overseas applications. Doctors, of all people, should know that you treat the disease not the symptom.

The partial fixes means that IMGs working for the NHS are already facing more problems. This year UKMGs (and a few others) are now prioritised for training, whilst Shabana Mahmood is threatening to increase the time required to achieve settled status.

The BMA position is odd. You would have thought that they represent their members, UK resident doctors, whether UKMG or IMG. Instead they hailed the lifting of the Resident Market Labour Test as a brave move. Despite this together with listing all doctor jobs as skill shortage jobs, causing the rapid worsening of the career prospects for new doctors. And only expressed concern about access to training a year ago. Their focus remains pay. Streeting acted quickly on training, and no doubt would act quickly on other career bottle neck issues, but is presumably waiting for the Doctors Union to raise them.

There are a wealth of other issues. Training selection is heavily weighted towards exam and research performance. The old adage that the closer you are to London the better your chances, still holds true. The talented, experienced and super-busy clinician based in somewhere like Blackpool, will struggle. Too busy holding the fort to find time for extras, and less access to mentoring or research. Those in DDs deanery had it even harder. New graduates are on the old Foundation contract, so with more hours and less time for study or formal mentoring. Yet training decisions are often UK wide. Virtually none of her F2 peers got onto training, yet most were from the area, went to the local University and wanted to stay. One of the few who did, an IMG, seemed surprised. HIs parents had paid £20,000 to ensure he had the right research, the right competition prizes and the right publications from his home country, all of which strengthened his application. Why weren't they doing the same? Instead those who get through will often leave the hard-to-recruit area as soon as a job comes up elsewhere, leaving senior posts within the training pathway vacant, and essentially unfillable.

There are so many things that could be done if NHS management were to really look to retain their good doctors. Long term, retention would save money and add stability. More pay is not the solution.

My daughter wanted to stay but it was unsustainable. She left for Australia at the weekend. She already knows of 15 from medical school or Foundation who are working in the same hospital. Each cost £400,000 to train and they will all be good. (Australian recruitment places a lot of emphasis on clinical skills, and this is a major hospital in a popular city.) She hopes that the NHS will get to a place where it is possible for her to return.

Long post, simple question. Why are the BMA just talking about pay, not about not talking about doctor un/underemployment. It is a very real issue.

I 100% agree with you. The junior drs I know are distraught about the lack of jobs. It seems incredibly tone deaf for the BMA to be whining about pay instead.

Having a guaranteed job to go to is not ideal either though. There are some shit doctors out there and having some competition for jobs is not always a bad thing.

I think you are right, but this shouldn’t be linked to the strikes. The government put forward proposals - I don’t know if these were enough, but they should have been debated separately and the government should not have taken their proposal off the table when the BMA chose to strike. These issues don’t just impact junior doctors ( although I can certainly imagine how they do) but are about wider efficiency in the NHS. The current situation is untenable.

That is surely more about weeding out unsuitable students? If they have successfully completed their training they should be, by definition, competent to practice.

Most countries in the world reserve their training jobs etc for their residents. So if you live in a country you are competing against fellow citizens for the training roles. The UK is rare in that it offers its roles to anyone in the world, so uk graduates are competing against Uk citizens and practically everyone in the world who cannot get a job in their own country. They flock to the Uk as one of the very few options they have.

I don’t think UK grads should AUTOMATICALLY get a job either, but the shouldn’t have to compete with the entire world for one, which currently happens.

Not in any way shape or form. There is an awful lot more to being a doctor than simply knowing how to do it.

Why? Our health system is entirely funded by us, the tax payers. I want to know that I'm getting the best value for my money and the best possible care. If there are better doctors overseas then bring them in! In the meantime, we need to be urgently looking at why overseas doctors are better, (if that is actually the case).

Yea but training should cover that - there should be assessment of not just technical competence- same as any other profession.

But this is not about every graduate automatically getting a job, there would still be the usual process, but prioritising UK graduates. Your comment could be equally applied to foreign graduates.

The UK is rare in that it offers its roles to anyone in the world, so uk graduates are competing against Uk citizens and practically everyone in the world who cannot get a job in their own country.

We've pretty much had to for the last ten years. Not enough doctors have been trained and loads left at the prospect of /after Brexit.

I completely agree and was unaware of the situation until a friend told me about her daughter’s situation. She has just finished F2 and wants to specialise in pediatrics. Despite applying to loads of jobs she was unsuccessful and has now applied to do a masters. It’s in a relevant subject and it’s only thanks to her parents paying for it. However she’ll be in the same situation again next year. It’s all well and good saying that they shouldn’t all expect a job but there is only one employer so they’re stuck.
My daughter is a vet student and will have limited options due to all the corporates but at least she’ll have a choice.

It depends on whether you are talking short or long term.

My daughter is good. Most of her friends are good. As are many IMGs. They will all have worked alongside doctors, UKMG or IMG who are not good, even unsafe.

It is the old problem, true of many occupations, that new entrants find it difficult to compete for jobs with those offering experience. But when they have that experience they might be even better. So when screening applicants for an entry level job, that guy who used to run his own clinic in India is more likely to be at the top of the heap than the F2 who only has six supervised placements to offer. But roll on 10 years and the more junior doctor could well end up as the more capable.

And if you set the competition levels so high, you are de facto wasting the £400,000 investment you have already made in the UKMG, along with the social costs of bringing in dependants, whilst splitting our young graduates from their families.

NHS recruitment is odd. They should have some idea of how good their F2s are from exam results, placement appraisals and references. But for equality reasons they don't use them. The very senior consultant in one of DDs placements, Prof somebody, who was a national expert in his field, actually offered to write DD a reference., He presumably liked helping dedicated young doctors at the start of her career. Of no use in the NHS, though the private locum agency loved it, and indeed used it to get her a job as cover for a busy Specialist Associate(!), albeit at half the post holders pay. Australia in contrast took references seriously and apparently did a lot of background work on applicants before interview.

They are not leaving because of Brexit. They are leaving because there is no work. 50% of last years F2 cohort, and probably about the same again.

Plenty, too many perhaps, are being trained, but there is a complete drop of at the end of F2.

The changes to immigration rules were made by Boris during Covid. They may have been needed then, but they should have been time limited.

I had no idea about this issue until recently. It does seem completely mad that there is an enormous backlog in the NHS, almost impossible to get a GP appointment and massive delays for treatment. Whilst at the same time having competent newly trained doctors not be able to get jobs

It isn’t just a question of money, or the lack of entry level jobs, or training, although all of those are contributory. It’s a question of the entire system, management, clinicians and everyone involved in the NHS, working effectively.

If communication isn’t effective and things are missed, patients suffer. If clinicians are rude and unapproachable, patients suffer. If patients are referred to the wrong specialism, they suffer. If their symptoms are dismissed, they suffer. All of these things have happened to me or friends of mine in the last year.

I agree that there is much more to being a doctor than knowing how to do it.

If junior doctors are striking for more money and more money is not the answer, but employment is, what will a strike for more money achieve?

Surely there is a way of retaining all the trained doctors.

I don't understand the BMa position. They want pay restoration to 2008. No one in the public sector is on anything vaguely equivalent to 2008 pay. Its almost 20 years ago and would be illogical to pretend that the world hasn't changed enormously since then

what will a strike for more money achieve?

More money for those in work.
Most doctors don't become consultants. Most remain in staff grade posts, and have few promotion prospects. (Though the SAS scale goes quite high. The Specialist Associate DD was covering for earned well into six figures in a very low cost area.)

I suspect the issue is that many in these posts feel trapped. Especially the IMGS. They came to the UK for a better life, willing to take an entry level post, and now find there is nowhere to go. Prospects are vanishing, so more pay is the answer. Some UKMGs will feel the same. Some will be happy, like one of DDs colleagues. Part time work, left in time to pick the kids up from school, secure work and really good pay/pension for the area. For another it was difficult. Their role involved lots of nights and they were desperate to find something with more regular hours. But there were too many locums and people on short term contracts as well as overseas applicants, so their chances were low.

If you are stuck you might as well strike for more money.

Why on earth did they lift the resident priority?

I assume timing, with Covid coming straight after we had lost many of our EU doctors.

The lifting of restrictions should have been time limited. Instead there is a whole industry of private medical schools on the sub continent and elsewhere pumping out more graduates than their countries can support, and further training for PLAB (a controversial equivalency exam overseas doctors sit which apparently has a higher pass rate than the UK equivalent) and and for specialist training. Not to mention agencies charged with recruiting doctors for the UK. The Times suggested, in a series of good articles a few months back, that one in six Nigerian medical school graduates now works in the UK. But then one in six of our recent F2s are probably working in Australia.

On a previous thread a dogged poster did a lot of cross checking of names running organisations/training schools in India (BAPIO the British Association of Physicians of Indian Origin was one example) and members of BMA/GMC committees. There was certainly the possibility of conflict of interest.

But then the BMA is an odd organisation that seems to be a confluence of special interest groups. This was the organisation that would not accept the Cass report, and stumbled over Sandie Peggie. It gets money from its under employed locums, but does not seem to do much for them.

One stunning claim in the Times was that there are 10,000 UKMG, but Australian trained, consultants in Australia, some of whom would like to come home but can't. (I think you can start applying for Australian training after 3 years of working there.) The BMA is blocking recognition of Australian specialist training even though it is virtually the same as ours. Instead those doctors have to spend years building up an equivalence portfolio whilst working as a locum before they can be hired as consultants by the NHS.

(in the meantime we are hiring consultants from overseas, perhaps on a locum basis, with no NHS experience, some of whom really struggle.)

I was at a party with an MP present, and did that awful thing of sidling up and asking if I could bend her ear about Doctors. As it was, in her surgery that morning a constituent had raised the issue of UK doctors not being able to return from Australia. The MP thought this was incredible, weren't we supposed to be short of doctors, until I told her it was all too true. She has since asked some good questions.

What? 🤣 Are you suggesting it isn't? Do you think that the selection panels look at applicants and says, yep, they're non-UK let's give them the job without any assessment?

No that's not what meant, I was responding to the previous poster saying that just because UK graduates have a degree doesn't mean they are good doctors- that's what I meant can be the same for foreign doctors. Appreciate that might not have been clear!

Edited for typo

I have heard that the situation is slightly improved this round of entry for UK graduates but not enough to ensure that the good applicants are getting the training posts.
There are shortages of higher level trainees actually working in the system due to a combination of more women in these posts who will be in their early thirties who have or want to have children and are either on mat leave or want to do reduced hours to fit in with childcare. The job is average 48 hour week (13 hours night shift, on call and long days). Quite often the men will want reduced hours because of child care. This extends the post Foundation training period from the minimum 7 years to 10-12 years. The training post is effectively blocked for those years and cannot be temporarily transferred. The work is covered by a locum (whether direct or through an agency) who cannot easily use it to help with their own development.

It is worth being clear. Good doctors can be educated in the UK, or educated overseas. Poor doctors can be educated in the UK or overseas. I think most of us would agree we need a system that promotes good doctors and weeds our poor ones. Resident priority when recruiting is a bit more tricky. Most would agree. Those that don't should consider the number of doctors from overseas who would like to work in the UK, and consider whether we need to train our own doctors at all. What is seriously unfair is to allow the taxpayer to spend £400,000 on them, and for them to dedicate 7/8 years building up huge debt, only to be without work.

Both the Government and the BMA now seem to agree that training is an issue. Measures are being taken to improve it. Not enough as @Whyhaveibeencutoutofmamsnot says, but then in a pyramid structure not everyone can be a consultant.

The issue I think is both the lack of work for the large pool of unemployed doctors (either those finishing F2, who have come to the end of a fixed term contract, or who are coming off a maternity break.) And the large number of doctors (either UKMG or IMG) who are stuck on entry level grades with no where to go.

The latter are fed up. Especially IMGs who are seeing their chances of accessing training evaporate. The BMA is suggesting strikes for more pay. If good performance and dedication are not going to get you a promotion, more pay would be at least a partial solution.

The BMA should also be talking about the unemployed. Because of the lack of resident priority the NHS is happily recruiting large numbers from overseas. UKMGs come onto the job market in August. This is when they need work. But Trusts recruit year round, and are obliged to select the "best" applicant. Very often that will be the one with the most experienced over an F2 with great appraisals and references. But there does not seem to be a BMA "unemployed Doctors committee" giving them a voice.

There are shortages of higher level trainees actually working in the system due to a combination of more women in these posts who will be in their early thirties who have or want to have children and are either on mat leave or want to do reduced hours to fit in with childcare.

This is not the only reason. DD did an F2 rotation in a department that had 8 out of sixteen training posts vacant. It was a hospital in a deprived area serving a large rural population. A reasonably sought after speciality, but urgent referrals were already up to two years, consultants were having to do one night on-call in four and there was little to no research happening. Not the sort of place that high fliers, whether Oxbridge/London or IMG would select. Better to wait till something comes up in a major teaching hospital or tertiary referral centre. Or do two years, apply elsewhere and leave.

DD and her peers would have been interested in one of those jobs and the department would have been pleased to have them. Unfortunately training selection is UK wide and they had not had access to the research opportunities available to other UKMGs and IMGs, nor the study time that those on the English F1/F2 contract have. When she started to locum and had to wait six weeks for her first shift, her first thought was to go back to that department and offer to do some audits. Unfortunately as she was not an NHS employee they could not give her access to patient data.

The work is covered by a locum (whether direct or through an agency) who cannot easily use it to help with their own development.

I agree with this. After six weeks waiting for NHS bank to process her application, DD switched to a private agency who told her not to worry. A lot of recruitment happened in August but by September people would start to leave. (A particular issue with some IMGs who will move to more diverse areas as soon as they can.) She became the fifth locum appointed to cover a Specialist Associate in a niche area with 25 very sick patients. Her predecessor lasted a day. 50% of the time she was on her own, with 4 F1s reporting to her. She was kept on six months, and would still be there had her Australian visa not come through. The work is relevant to the area she would like to specialise in. But because the work was zero hours, through an agency and not classified as a Clinical Fellow role, she gets no credit for it and she can't log it on her record.

The NHS is saving money through pay erosion and by recruiting experienced staff into lower grade jobs. It is a false economy if you can't retain. In a couple of years time, when the reduced access to training makes recruitment of IMGs more difficult DDs Deanery will wonder where all their capable F2s went. Overseas private medical schools in places like Penang, live or die on their success in getting students into good programmes abroad, and provide strong support. All that happens in the UK is a P45. At least a quarter are now in Australia. Dedicated young doctors who would have been only too happy to build their careers in a hard to recruit area.

Anyone who thinks that IMGs are “better” should take a look at the GMC sanctions data, which states that,
“IMG doctors are significantly overrepresented in sanctions relative to their proportion in the workforce”. One could make an argument for potential bias in the system, or that there is just a relative competence at play. My own recent experience in hospital would reflect more of the latter.