It’s clear, despite widespread junior doctor support for further reasonable industrial action against imposition, that the BMA has folded. Now in full “supporting transition” mode, the early imposed trainees already report chaotic rotas, trusts skipping pay protection clauses and lack of coherent safety reporting structures. Many doctors have left, or are considering leaving, the BMA.
Obviously into the midst of this Jeremy Hunt puts the boot in. Keen to build on the perceived political capital of pushing the BMA into withdrawal and supposedly ‘winning’ his High Court case against the contract, he goes onto announce plans to chain doctors to the NHS for four years after qualification, and to replace the ‘foreign’ doctors that prop up the NHS as it is, with ‘homegrown’ doctors. His plan to expand medical student places by 1500 a year starting from 2018 isn’t unwelcome – it’s just dangerously unrealistic and overtly xenophobic. Doctors entering medical school today will enter the workplace, chained to the NHS, in 2021/22.
What will life be like then?
It’s fairly straightforward to extrapolate UK demand by 2022, and the Nuffield Trust have already done the work [ref]**. They report from 2014 predicted NHS demand, expressed in bed days, will roughly rise by 1.7%/year. That means by 2020/21, demand will have risen by 8.7% and by 2021/22, 11% compared to today.
By 2021, bar any dramatic announcements in the Autumn statement, the King’s Fund predict NHS funding in real-terms will rise by £4.5 billion, a rise of 4%. However, the current deficit this year is £1.8 billion, so this is actually just £2.7 billion to spend, a true rise of just 2.3%*. Meanwhile, hospital demand will have risen by 2020/21 to 8.7%, which means each extra pound will need to work four times as hard just to stand still. Given waiting times in A&E and surgery have never been longer and the current deficit is the largest ever recorded, the system already appears to be stretched to crisis point. Imagining it can now stretch to accommodate an efficiency of four times what it currently can achieve is lunacy.
This prediction also relies on being able to discharge patients, reducing pressures on hospital, but social care has also had it’s funding slashed, back to just 0.9% of GDP by 2020, with an estimated shortfall there of £3-3.5 billion. It’s not going to get better.
Hospital bosses know this, and have already spoken out. NHS Providers CEO Chris Hopson and NHS Chief Executive Simon Stevens have both said current funding is unsustainable .
What will that look like on the ground? Well, resources will be diminished, pushing people out of hospital beds will become more commonplace, and with no staff budget more and more hospitals may have to close departments due to lack of staff to run services safely. Here is a list of sixteen hospital departments that have closed this year. Expect this to grow. This might mean working in hospitals without services on site, sending patients miles away and arranging urgent transfers to other hospitals, which is less safe, and very time-consuming, to already overstretched staff.
As of 2015, there were 41,165 consultants and 36,919 GPs in the NHS, plus 54,000 junior doctors, with 25% of them trained overseas, either EU or non-EU. For GPs and consultants, the NHS plans to increase this by 5000 a piece, or 14% by 2020. However, new workforce modelling predicts we may need as many as 12,000 more GPs to run a thread bones service, and 24,000 to run a safe and well staffed one.
I can’t find the numbers of junior staff required, but if we simply match demand in 2024, 14% compared to today, the ‘extra’ doctors would need to be 7560 more than today. It would taken ten years to catch up to demand, by 2034. That’s a huge deficit to walk into.
There’s of course a plan to expand the numbers of non-doctors to fill the shortfall; non-medical endoscopists, surgical assistants, physicians assistants are all already active in the NHS. What this will mean for junior doctors is hard to gauge – it may help training, it may hinder, and a lot of work will need to be done to work out how workplace issues such as medicolegal responsibility and training will be impacted by the increasing use of non-medical staff doing work previously done by junior doctors.
And that’s of course assuming all the ‘foreign’ doctors are allowed to ‘stay’. Theresa May claims they can stay until at ‘least’ 2025, but why would they? If even 10% of the overseas trained doctors left the NHS in the next ten years, it would be utter cataclysm.
Needless to say, being chained to an organisation for four years, that requires you to stretch four times more work out of it’s resources compared to today, that’s missing thousands of staff, with hospitals in various states of closure, might dampen morale.
The imposition of the new contract for junior doctors of course will only make all of this worse. As budgets are tightened further cuts will need to be made to staff groups – the strikes this year will be far from the last to hit the NHS.
Ultimately all of this speculation relies heavily on the idea an NHS will still be the main provider of healthcare in the UK by 2024. Looking at the staffing, financial and patient demand projections, no credible plan emerges to preserve the NHS. Services will slowly degrade, and more and more private options will come available. Already a private Uber-style service is emerging into the current GP crisis. This could be the snowball that starts the avalanche, as more and more wealthier citizens are pushed towards private healthcare.
My point here is the battlefield ahead is perilous, for patients and staff, as we are guided by NHS bosses that are unheard and ministers either deliberately or incompetently steering us towards rocky shores. Whatever Jeremy Hunt’s plans, 1500 doctors a year will not make any impact whatsoever in 2024, far from being ‘self-sufficient’, and we will have huge crises in senior staff and resources that no amount of fresh-faced ‘homegrown’ graduates will solve. If our hardworking and invaluable overseas staff leave, the NHS will collapse instantly.
That’s the future of the NHS and junior doctors – bleak isn’t it?
So what are you going to do about it?
*This assumes there will be no deficit for the next three years – an extremely tall assumption. More likely, there will be no extra money whatsoever.
**barring some huge paradigm shift in medicine, or an epidemic disaster. Brexit may count in this respect – the fall in the pound vs the Euro has made medicines more expensive, and the loss of research grants has made teaching hospitals poorer.