A Discriminating View of the Doctors' Staffing Crisis in the NHS

We are going through extraordinary times for the NHS, especially so for doctors. From my perspective, this reflects the effect of not getting it right for everyone from the beginning.

The NHS as a care delivery model is fantastic. Tax funded, free at the point of care delivery, delivered at more or less the same standard across the country. It is so special, no doubt about the model/pathway.

The issue comes when it comes to staffing that delivery model. There was simply no staff at any time to deliver this model. So quite simply, as was always done in British history, the UK looked abroad for resources (the detriment to other countries by this policy is till today ignored by the UK). For healthcare the crucial frontline resource - the doctors were simply imported, poached, stolen (you can choose whichever word you want depending on the perspective) from abroad. India being a country which has medical education delivered in English following a British system of medicine was a natural target. For ages, even till today many IMGs end up as GPs in inner city and deprived areas. But it is the hospital medical hierarchy where the glaring disparity hits you.

There was always a surplus of registrar and senior registrar posts compared to the consultant posts (there was a permanent pyramid). Now that may be a problem in itself leaving people without opportunities. What happened from the mid 1970s onward, the demographics of the pyramid shifted. In the registrar and senior registrar grades there were mixed ethnicity with plenty of IMGs but very few of the IMGs went on to become consultants. The locals were in line for progression to a consultant post barring unforeseen circumstances and the IMGs were to remain permanently as registrars and senior registrars barring unforeseen circumstances, till they retired or died. These were later called staff grades and associate specialists. Name change and plenty of warm talk but the intention and roles remained the same. 


In the late 1980s and early 1990s I have heard numerous that local graduates holding registrar and senior registrar posts stated openly, loudly and clearly that they will put up with difficult conditions and low pay because it is only for a relatively short time before they became consultants. Meaning, that locals will progress on to higher pay and the IMGs will remain on the lower pay. This suited a brilliant care delivery model to be delivered at a low cost using a rubbish discriminatory unjust medical staffing model.


Of course, this strategy would have worked except that more consultants were needed and there were not enough local candidates. By late 1990s early 2000s the system woke up to this and created more medical school places and in my view with the hope that this local - IMG differential would continue. Where it went wrong primarily is that they underestimated the impact of women entering medical school, like most men, most women are excellent doctors but firstly they also want a good lifestyle (in contrast to men who in my view were often married to their careers) and more importantly physiology demands that many women choose to have children. So workforce planning went for a six; more IMGs were needed and the flood gates were opened in the early and mid 2000s. 


You see, now, suddenly, the pay for doctors is thought of as high, suddenly evening and weekends are no longer want to be considered as premium pay time. When medicine was overwhelmingly a white, male profession with IMG men manning the lower ranks these were not issues, doctors pay was relatively high compatible with their education and contribution, weekends were precious. The demographics change to equal number of women and a large number of IMGs and the values change.

The next wrong calculation comes from the fact if UK thinks they can import their way out of this mess. I don't know about other countries but many Indian young doctors are very wary of coming to UK; the training opportunities have increased in India, the economic opportunities have increased in India and lifestyle is improving in India - the exchange rate alone is no longer attractive.

To me it seems that the establishment does not want medicine to be an elite profession as it was when it was white male dominated. This makes it distinctively unattractive. There was always discrimination, there still is; the difference now is that there is FOI, there is corporate social responsibility and transparency. In the past we knew IMGs failed exams but we did not know the numbers, we always accepted that we did not reach the necessary standard, we were expected not to reach the standard, we were brought up being told that we could not reach the standard. None of that bullshit anymore. We know the numbers which are spread immediately all around the world by email, whatsapp, fb and twitter. We are asking questions; does the Indian IMG paeds reg trained in UK and taking the exam in UK have a higher failure rate in the UK version of MRCPaed than the Indian paed trainee who takes the exam in India never having worked a day here? Does the MRCGP International AKT MCQ have a longer time to answer their question than MRCGP UK which puts IMGs at risk of failing a 'purely knowledge exam'? We suspect an adverse use of linguistic bias. We know that Scottish, Irish etc need a grade c in English equivalent to IELTS 6.5 but IMGs need an English standard much higher, yet found fault with their language. We know the students in England do not need English A levels to get into med school. The standard for IELTS for IMGs was not set by administering to a group of local FY2s, it was actually set by an equivalent of a large focus group sitting around a table and deciding what was an acceptable standard; what a marvelous way of standard setting (accompanied by truck loads of stats on why that kind of standard setting was valid, the whole lot I found dubious, okay, to put it politely, it was very highly subjective)

The senior doctors including senior IMG doctors seem to have a distinct mentality that is not quite in sync with the younger doctors and their aspirations. The true cost of discrimination against women, discrimination against IMGs is now biting back.

A fabulous care delivery model designed six decades ago by the local population for the local population in UK did not consider the career prospects of IMGs and did not care that women were not part of the game for a long time are now completely flummoxed when IMGs are waking up and women are demanding a different kind of atmosphere. 


I wait to see if the lessons from past atrocities will be learned, I wait to see if because of the change in demographics medicine will be deliberately made into a lesser profession. I am not optimistic about the people becoming just. Why am I not optimistic? Let us look at the current routes into UK for IMGs - the MTI and the PLAB.


The whole MTI premise is based on getting people into UK to fill in rotas. It would be very difficult to provide any proper training in two or three years; especially when MTI doctors are not deanery numbered trainees for whom there is still to some extent funding for training. When I look around, I find that most new entrants into UK are in rota fodder posts and not in any proper training posts. I am not sure if there are large number of MTI doctors who are undergoing specialised training  (say for instance in pancreatic transplants), I suspect most of them are at SHO and junior registrar levels.

Let us say that a doctor goes back to India after MTI and applies for a job in a corporate hospital in competition with a CCT holder - who will get the job? Let us say an MTI completed doctor applies for a job anywhere else in the world (middle east, australia, etc) what kind of a job will (s)he get on the basis of MTI? Has anyone asked these questions? My personal feeling is that in most of the cases a typical MTI doctor after the completion of the time and leaves UK as per the rules is unlikely to be a strong candidate for any job anywhere in the world (I am sure there will be exceptions to this assumption).


So what is the use of MTI posts? 


The next is PLAB route doctors who more often than not spend years in a variety of non-training posts. My advice to young doctors who come to UK after PLAB process is 'take a formal training post or do not take a post at all in the UK'.


If still doctors from India want to come to UK via MTI or accept a non-training post via PLAB then the only logical reason for that would be to use UK as a temporary staging post to analyse and access opportunities in the rest of the world eg prep for USMLE etc.

UK should stop looking at IMGs as rota fodder. The system should change to provide every doctor who enters UK only formal training posts with the intention of making them a consultant or a GP; there may be some who eventually choose not to practice as a consultant and take up a senior non-consultant post, that would be a matter of personal choice and not a systematic denial of opportunity. This means at junior levels there are only training posts. Well, will this ever happen, I wish it would but I am pretty certain it won't. The system is designed for and habituated to exploitation of the IMGs; that system is unlikely to shock itself by changing even when it faces its own existential crisis.

So unless there is a technological solution there is going to be an ugly muddle impasse in the NHS for a long time to come.

©M HEMADRI

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My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html

 

Seven Day NHS from a 2006 perspective

The seven day NHS debate has been raging for a while now. People die over the weekend, people do not die over the weekend, weekend should become normal time, there are no staff, there is no money; the arguments are plenty.

Interestingly in 2006 I looked at this issue from a flexible working, work-life balance, ‘flexible weekend’ perspective. I did a sample survey of a small number of people and then qualitative interviews of an even smaller number of people.

The quest was to find out if NHS employees had the ability to choose your own two days off in lieu of the traditional Saturday-Sunday weekend off would they go for it?

My own personal view at that time was that employees would love the flexibility and really go for it. That was my mental construct, assumption, bias at that time; though I tried my best for my views not to interfere with my study. Once the study was done, I realised my assumptions were completely wrong.

The findings were fascinating:          

More than 70% felt there would not be enough staff to enable the system to run a routine 7 day NHS service

56% did not prefer to have the ability to choose their own two day weekly break (they would rather stick with the standard Sat-Sun)

66% felt that choosing their own 2 day weekly break/off days (in contrast to the traditional Saturday-Sunday weekly break/off days) will not improve their work-life balance.

61% felt that once this ‘choice’ of being able to choose their own weekly two day off was introduced they may be forced to take specific days off which may not really be of their choice

My views now

These findings from a good representative cross section but small number of NHS employees with a good rate of response to a questionnaire and from a selected representative employees personally interviewed in detail for qualitative analysis.

Firstly, it almost prophetic, that normal NHS employees even in 2006 felt that we would not have enough staff to run a seven day NHS. Those were the days staff numbers were growing and money was not tight; yet they felt that way. It seems even more true now.

Next, the importance of family and social life was based on having the weekly break on days common with family and community. Hence the ‘choice’ of the ability to choose one’s own days off in the week turns out not be a choice at all since it does not suit families and community.

The most alarming was the degree of distrust of the system and the managers – the employees felt that what was offered as a choice now could morph into something that they might be forced to do down the line.

We can see all these magnified big time in the junior doctors’ dispute – shortage of doctors, importance of a family/community oriented work-life balance and huge distrust of the system.

I paste some extracts of the study below to give you a bit more of the flavour.

It seems that the normal employee and the powers that be hold contradictory views. In that context if employees feel forced to do disliked activity engagement falls and unhappiness will rise - that cannot be good for patients. If the forced changes remain in place for long, new employees may know no different in the context of their employment but it will have severe impact on families and community - is that a price worth paying?

©M HEMADRI

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My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html

 

READ ON......................................................

REASONS FOR WANTING TO CHOOSE ONE’S OWN PERSONALISED WEEKLY OFF-DAYS

‘If it changes week to week, it would help us to get things done during ‘week’ days’

Leisure ‘facilities will be available on two full days and will be less busy’

Will choose Fri and Sat as alternate days off

‘I like having Saturday Sunday off. Husband works 5 days a week. Son at school. Sat-sun only time apart from annual leave that we have quality time as a family’ I will choose Sat-Sun as my preferred days.

‘I would like days off in the week during school holidays to spend more time with son and to cut down on child care expense’

‘It will help me with child care’

‘Friday prayer’

Will choose Thu/Fri.

‘My husband and daughter get week-ends off, so I would like to be at home with them’ I will deliberately choose Sat-Sun.

‘My husband is off work on sat and Sunday, (if I chose this scheme) I would be working when my family is at home’.

‘Working part time I have the flexibility of having two days off in one week as well as being off at weekends. It really makes no difference to me what two days I have off in the week’.

I like to have sat sun at home. My daughter is at an age where I do need to care for her. I do understand the reasons, as when she was younger I worked nights to accommodate her school hours.

To reduce stress I would like to break up my working days. Choose Tuesday and Friday off

REASONS FOR NOT WANTING TO CHOOSE ONE’S OWN PERSONALISED WEEKLY OFF-DAYS

‘Other family and friends have their weekends on Sat/sun’

‘Will lose contact with my kids’

‘My activities involve other people up and down the country and everybody may not be free on the same day’

‘Working on Saturday-Sunday can be mentally taxing’

‘Can’t coordinate with friends and family’s off days’

My husband and daughter are not at home Monday to Friday’.

‘My job would not be suitable for me not being here on two days during Mon-Fri. Patients would be unaware of my being here on Sat/Sun and would expect me to be available Mon/Fri’

WEEK-END WORKING AND VIEWS ON THE STUDY OPTION

A large number (20/23, 87%) of respondents worked weekends. This could superficially suggest they were in favour of flexible working or extended working practises. However, the weekends in almost all cases are mandatory contractual conditions being part of the job rather than due to an active choice by the respondent. There are nearly no opting out clauses from weekend work in many circumstances except perhaps on grounds of ill health.

Weekend working which is contractual was not seen by the employees as a form of flexible working practise. They did not mark it as a flexi-practise anywhere in their responses of their awareness and use of flexi-work. In the above contexts, working weekends as a mandatory part of the job could perhaps be construed as an ‘inflexible working practise’

Concerns about flexible working

It emerges that one of the main reasons for being wary about the choice of the concept of this study is that the employees may be forced to ‘take specific alternative days instead of Saturday/Sunday’. This is how it currently works with weekend work by ‘rota’ for doctors and by ‘self-rostering’ for nurses. The opt outs from such rotas are either rare or non-existent. Logically there is a fear that this choice will become an obligation or an enforced choice rather than a true choice with no benefits in return.

In the free hand responses the main theme that emerges is the family. The family was the reason why most respondents would not want any other days other than Saturday/Sunday as their weekly break lest it disturb their current family arrangements. In fact one illuminating response was that the Saturday/Sunday break was a positive ‘preferred choice’ due to the current established social more of mandatory weekly holidays so that the quality of cherished family experience is retained.

PERSONAL REASONS

Some managers saw immense advantages to their particular family situation. However it could be argued to what extent would or should an organisation match with the employee’s family situation which by logical extension, as seen in the study, to the employee’s spouse’s arrangements. It can be understood how this can cause complex administrative difficulties.

The staff and the managers in this study gave similar reasons of family, work, difficulty in organisation and ability to provide a seven day service as affecting their choice of accepting or rejecting the proposed model, but came to different conclusions with the staff unwilling to accept a personalised weekly off-days and the managers seeming keen about it. The inference here is that the same scheme that suits the manager’s families seems not to suit the staff’s families. Hence suiting individual families seems an issue of primacy.

COMMUNITY ORIENTATION VS INDIVIDUAL ORIENTATION OF LEISURE TIME

One manager said, ‘I don’t think a common weekly day off for everyone is that important’.

That statement contradicts the view of the Keep Sunday Special (2006) lobby arguments. The KSS feels that social capital is lost and engaging in community activity is affected by not having a common weekly day off. They quote USDAW poll where 92% of shop workers do not want an extension of the present working and NOP 2005 consumer poll where nearly nine out of ten people said that it is important for family stability and community life to have a common weekly day off. However the facts are that Sunday shopping is present and growing. The availability of online shopping and 24/7 weekday shopping and the argument to treat retail equal with other businesses such as restaurants and hotels makes an argument to treat Sunday different a weak one. Leisure is now commercialised and commodified and could be considered an industry. Hence, the question of communal leisure has to be weighed against individual choice. The difficulty is in understanding whether individual choice is truly available or is constantly overridden by organisational needs.

This debate emerges in this study as well in the form of staff being wary of being forced to opt for a ‘choice’ that they do not prefer and with the managers being enthusiastic about the study subject whether organisational priority would hijack individual choice.

THE NHS CONTEXT

Perhaps the average employees experience and perceptions have been shaped by the origin and difficulties faced by the ‘work-life balance issue’ with women having had to go part time, difficulty in returning to full-time work, gender based pay differences, the economic pressures on employees especially on women and single income families, increasing stress, decreasing satisfaction and the employer profitability orientation of the general debate. This could have played a part on our respondents being wary of new initiatives on ‘work-life balance’.

The evidence suggests that larger organisations offer flexible working practises including a wider range of the modes of flexi-work. Our institution being an NHS Trust hospital therefore fits in the profile of a large organisation and the proposed extension could be offered to increase the range of flex-work programmes.

The findings in this study is compatible with the evidence in the literature that shows that managerial, highly educated and high-income workers are more likely to take up flexible working since it is thought that they are more likely to benefit from organisational changes (Nisar). However in this study we also find that doctors as a group though fit into the profile who according to the literature are likely to embrace flexible working rejected the concept. This could be due to the specific situation of doctors whose terms and conditions are in general nationally agreed and set. Further since they already working shifts, weekends, on-calls etc they feel any further expansion of flexi-work as proposed could be manipulated to impinge on working styles, training and personal time.

There is a history of compensation for adverse working conditions. Weekend working is hence compensated with premium rates. The proposal under question offers choice but the findings could be interpreted as the loss of the opportunity to earn premium rates in the guise of offering an increased choice.

It has been argued that flexi-work arrangements are one of the many strategies such as flat hierarchies, horizontal networking, multilevel skills, team and employee involvement in operational decision making, to implement a decentralised organisation. But the evidence of this in practise is very limited (Nisar). It could therefore be surmised that in the absence of a package to effect truly decentralised organisation, the offer of flexi-work or its extensions may not have much takers.

In Senge’s view: “the fundamental flaw in most innovators’ strategies is that they focus on their innovation . . . rather than understanding how the larger culture will react to their efforts.”

©M HEMADRI

Follow me on Twitter @HemadriTweets

My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html