Doctor Training

Anthony Browne Excerpts

Tuesday 17th January 2023 Westminster Hall

[Anthony Browne (South Cambridgeshire) (Con)]

I beg to move,

That this House has considered the potential merits of training additional doctors.

I shall start with a quiz. Who does not like a quiz? What do Members think is the most common nationality among doctors working in the NHS who trained as doctors in Bulgaria? I know that sounds like a silly question—surely Bulgarians train as doctors in Bulgaria and come to work in the NHS—but no, two thirds of NHS doctors who trained in Bulgaria are British, not Bulgarian. Indeed, there are more British people training to be doctors at a medical school in Plovdiv in Bulgaria than there are at Plymouth medical school in Britain.

I imagine Members are thinking, “That makes no sense. How can it be?” Well, those bright, young British people who are clearly capable of being doctors could not get places at medical schools in the UK, so they went off to be trained in Bulgaria before coming back to the UK to work in the NHS. Members might think that that is a stroke of genius by British policymakers—getting other countries to train our doctors; think of the money that saves the Treasury. This has been British Government policy for decades: we do not need to train enough doctors for our needs because other countries will train doctors for us, and they will come to work for us anyway. The purpose of the debate is to show that that Whitehall orthodoxy is not just seriously flawed, but against our national interest. It also harms some of the most deprived countries in the world.

The Government launched their independent NHS workforce review at the end of last year, and it will look at many of those issues. I look forward to hearing the Minister’s thoughts on the review. The purpose of the debate is to step up the political pressure to ensure that the Government reach the right conclusion, which is that, as a country, we should aim to train enough doctors for our own requirements.

I should declare that I have a big constituency interest in the issue. South Cambridgeshire is the life sciences capital of Europe with a biomedical campus, two major hospitals and two more planned, countless world-leading medical research institutes and hundreds of life science companies. All those are impacted by our national refusal to train enough doctors for our needs.

The first thing to say about our national policy of not training enough doctors is that it has clearly failed. We would have to be hermits to be unaware of the pressure the NHS is facing, with record waiting times at A&E and waiting lists for operations. There are many reasons for those, such as it being winter and the covid backlog, but one of the biggest structural reasons is the workforce. There is a shortage of medical workers of all types, including nurses but in particular doctors, and there are a staggering 132,000 vacancies in the NHS of which 10,000 are for doctors. A recent survey by the Royal College of Physicians found that 52%—more than half—of advertised consultant posts went unfilled, primarily because no one applied for them.

Despite being among the most interesting places on the planet for doctors to work—I agree; I am biased—even my own hospitals in South Cambridgeshire struggle to fill their posts. Across the country, there are doctor deserts in which health authorities have real problems in getting doctors to come and work, and rural, coastal and inner-city areas are struggling the most to fill their vacant posts. The Government are trying to implement their commitment to increase the number of GPs by 6,000, which I strongly support, but in reality, the number of full-time equivalent GPs has been dropping by about 1% a year. There just are not enough doctors.

The international figures highlight the scale of the problem. The UK has just 2.8 doctors per 1,000 people, which is significantly below the OECD average of 3.5. It is even further behind the figure for some of our European neighbours, which have more than four doctors per 1,000 people. To reach the OECD average, the NHS would need an additional 45,000 doctors. Imagine the impact they would have on our waiting lists.

Desperate hospital managers are driven to fill the gaps by employing locum medical workers at pay rates vastly greater than they would be if those people were employed directly, and the bill for locums across the NHS is a massive £6 billion a year—a huge waste of taxpayers’ money.

I do not need to labour the arguments: there is a clear political consensus that current NHS workforce planning is not working. There are many short-term and medium-term sticking plasters for the NHS workforce crisis. We need to reduce the number of doctors who leave the NHS through early retirement, leave for other professions or seek a better life overseas. We need to retain more doctors through improved conditions and financial incentives. We need to improve working practices to give doctors greater flexibility over their lives. We need urgently to update the nonsensical pension regulations that are forcing experienced consultants and GPs to retire early.

Another medium-term solution to reduce strain on doctors is empowering physician assistants, nurses and pharmacists to take on additional duties through new regulations, for example on prescriptions.

[James Sunderland (Bracknell) (Con)]

I commend my hon. Friend on his excellent speech; I agree with every single word. Would he recognise that the inflow of doctors to the NHS is part of a wider package? He alludes to the appalling high salaries being paid to locums. That is preventing doctors from getting contracts for surgeries locally, which is a problem in Bracknell. Would he also agree that we have to bring doctors back from retirement and other professions? That is about improving inflow at every level, across the whole of the service.

[Anthony Browne]

I agree fully with my hon. Friend that training more doctors is just one part of the solution. There is no point training them if they suddenly leave. We need to ensure that they are not incentivised to retire early, and that they stay working in the NHS.

According to a study by the health consultancy Candesic, only one in four pharmacists are currently allowed to prescribe; 6,000 pharmacists a year could be trained to prescribe, at a cost of £12 million a year. Those are all things that we should be doing anyway, but they will clearly not solve the problem on their own.

The NHS has historically attempted to make up the shortfall of doctors by hiring them from overseas. That decades-old Government policy means that the majority of new NHS doctors are now trained overseas. Only 45% of doctors joining the General Medical Council register last year were trained in the UK—less than half. A similar percentage were international medical graduates from outside Europe, and the remaining 10% came from the European economic area.

Those overseas medical workers keep the NHS going; they provide expertise and care and are part of the exchange of ideas and experience that drives medicine forward. They are very welcome, but relying on other countries to train our doctors for us is not a long-term, sustainable solution. First, it leads to a global doctor shortage, which harms the world’s most vulnerable countries the most. We are far from being the only rich country to try to save money by getting other countries to train doctors for us. In fact, when it comes to training doctors, we are in the middle of the pack. We train 13.1 medical graduates per 100,000 inhabitants. That is more than the US, at 8.5, and Germany, at 12 per 100,000, but we are behind countries such as Italy, at 18.7 medical trainees per 100,000 people, and the world leaders, Ireland, at 25.4.

The World Health Organisation estimates that the refusal by rich countries to train enough doctors has led to a global shortfall of 6.4 million doctors. It is the poorest countries, which can least afford to retain their doctors, that are most harmed. The NHS tends to recruit predominantly from south Asia and Africa. According to the GMC register, the UK is now home to 30,000 doctors from India, 18,000 doctors from Pakistan, 10,000 doctors from Egypt, 4,000 doctors from Sudan and 3,000 doctors from Iraq. Nearly all those doctors were trained in the medical schools of their home country and left to join the NHS.

Many of those countries need their doctors even more than we do. Sudan has a doctor-patient ratio of 0.3 doctors per 1,000 people, a tenth of our doctor-patient ratio. Infant mortality at birth in Sudan is ten times higher than our own. It is ridiculous that our international aid budget is paying for health projects to try to improve health outcomes in those countries, while we strip them of their doctors. If we had supplied 4,000 doctors to Sudan, we would rightly be proud of the help we had given, but instead we recruited 4,000 doctors from Sudan. Countries such as Sudan need our support, rather than our laying out the red carpet for their medical professionals.

The WHO responded to this by setting up a red list of 47 countries that are deemed to have a low doctor-patient ratio, from which other countries should not recruit. That is a step in the right direction. The NHS no longer actively recruits from those countries, but passive recruitment continues apace. The GMC still offers professional and linguistic assessment board tests in countries such as Sudan, Ghana, Pakistan and Bangladesh. In just the past year, another 500 doctors joined the NHS from Sudan, even though the Government are supposedly not recruiting from there.

The global doctor shortage is likely to get worse, as countries age and economies grow, and demand for healthcare increases. It would be foolish to think that we can always rely on importing doctors whenever we want them. We face increasingly stiff competition from the global market. From a workforce planning perspective, it is significant that the retention of UK-trained medical graduates is higher than those trained elsewhere. Nine in 10 UK graduates who obtained their medical licence in 2015 still had it in 2021, but that was the case for only two thirds of international medical graduates, and less than half of European economic area graduates. We need to minimise leakage from the NHS workforce if we are going to stop the vicious spiral of staff shortages.

The only long-term, sustainable solution, and the purpose of this debate, is to train more medical workers, particularly doctors. This really is a long-term solution, as it takes 10 to 12 years to train a GP and even longer for a specialist, but that is all the more reason to start now. We need to ensure that the supply of doctors is sufficient for our national needs, and that we retain them for the span of their whole career. It is a conclusion that the Government have arrived at before: it was once championed by the current Chancellor when he was the Health Secretary and as Chair of the Health and Social Care Committee. The Government announced an ambitious plan to increase medical training places in 2016, creating 1,500 more places—a 25% increase on the existing number. That was then the largest single uplift in our history, and it was very welcome. It was no mean feat and required the building of five new medical schools across the country, but it is still not enough.

We need to be bolder if we are to aim for self-sufficiency. It is an ambition that has widespread support: the Royal College of Surgeons, the Royal College of Physicians and the Royal College of General Practitioners are all calling for it. The British Medical Association and the Medical Schools Council support it. As I understand we will hear today, it has cross-party support. Last year, just short of 16,000 doctors joined the register. To meet our national needs, we need to double our number of training places by adding at least a further 7,500 to the existing 7,500, making a total of around 15,000 training places.

[Antony Higginbotham (Burnley) (Con)]

My hon. Friend makes a compelling point. Does he agree that we do not have to do a massive expansion of medical schools to expand the number of medics we are training? In Burnley we have the University of Central Lancashire, which already trains medics, but the number it trains for the UK is relatively small; it does a far bigger international programme. The university is more than willing to switch that over and train far more here for the UK. We do not need a massive number of new facilities, so the capital cost is relatively small. It is just about saying to the medical schools, “You can train more UK students.”

[Anthony Browne]

My hon. Friend makes a really interesting point, which I was going to touch on later. I was going to call on the Government to do a feasibility study of how we get all those extra training places, using the existing resources that we have. I was going to mention one: we now have the first medical school in the UK that does not train any UK graduates; it only trains international graduates. The facilities are absolutely there, and we need to make the most of those to start with.

I should say that training enough of our own doctors does not mean an end to international movement of doctors, and nor should we aim for that. A steady exchange of internationally trained doctors around the global health system is a force for good. It provides opportunities for doctors to experience best practice in other countries and encourages knowledge sharing, and long may that continue.

Now that the policy has cross-party support and backing from the medical profession, why are we not already training enough doctors for our needs? Well, I am afraid to say the main stumbling block has been the Treasury. The perceived wisdom in the Treasury is that it is cheaper to recruit doctors from overseas than to train them ourselves, which might be true in the short term. Medical school places are highly subsidised. Estimates vary, but it costs around £200,000, if not more, for the Government to send a student through medical school. The additional 7,500 places would equate to an additional £1.2 billion a year.

However, on closer inspection, the financial argument does not really add up, certainly not in the medium or long term. First, a considerable proportion of a trainee’s time is spent providing clinical care to patients, so training more doctors will mean that hospitals can spend less money on recruiting locums to provide the care that trainees could provide. Secondly, training more doctors will reduce the £6 billion cost of locums overall. Investing in the training of doctors will save the Treasury money in the medium term as we reduce our dependence on agency staff. Thirdly, the financial argument neglects the income tax receipts earned by the Exchequer over the lifetime of a doctor. An excellent paper just published by the think-tank Policy Exchange calculated that there is a net additional positive lifetime return to the Exchequer of £183,000 for women and £398,000 for men—why is there a difference, one might ask—compared with the most positive plausible alternative degree. In layman’s terms, the Government make a greater return if they train someone to be a doctor than if that person pursues a degree in chemistry or pharmacology.

Concerns have also been raised that taxpayers will pay for the training of doctors, who will then simply leave for countries such as Australia and New Zealand in search of better pay, working conditions and, indeed, weather—who can resist the Australian sunshine?—but that is easily sortable. The Army provides medical bursaries worth £75,000 for Army medics, in return for which they must commit to working for the Army for four years. The Government should adopt a similar policy. Trained doctors should have to commit to working for the NHS for a set period, such as four or five years; otherwise, they would have to repay a portion of their training costs.

If, as I hope the Government will do, we decide to train an extra 7,500 doctors a year, how do we make that happen? My hon. Friend the Member for Burnley (Antony Higginbotham) made this point earlier. Implementation of training places is difficult, but it is doable. We have done it before. Training a doctor is complex. There are interdependencies between different bodies that require collaborative thinking and co-ordination. To achieve 7,500 more places, we will need to not only increase the capacity of the existing medical schools and switch places over from international training, but also build an estimated 15 new medical schools.

Each new school will need access to hospitals with clinical training facilities. There would need to be enough clinical academics to conduct the training. Newly qualified doctors will need access to postgraduate courses, including foundation and specialist training.

Despite those hurdles, we managed to increase places by 25% following the announcement in 2016. We can do that again, on a greater scale. I am looking for a commitment from the Minister that the NHS workforce plan that is due out this year—it may be independent, but I am sure the Government have their view—will not only outline an ambition for the UK to do enough medical training for its own requirements but will also include a realistic plan of how that ambition could be implemented. Will the Government launch a feasibility study into how medical school places can be doubled to 15,000 by 2029?

In the meantime, on the path to that ambition, will the Government commit to reinstating the funding provided for additional medical school places during covid for the next academic year? That is a straightforward way to boost capacity in the short term.

Finally, there is a real problem with the transparency of the workforce in the NHS, because of the lack of data. Will the Government commit to providing third-party access to electronic staff records to encourage greater understanding of medical career lifestyles in the NHS?

There are other benefits that flow from increasing training places for doctors. At present, we have many hard-working, straight-A students who are perfectly capable of being excellent doctors but are denied places at medical school. Last year, the rejection rate at medical schools was a staggering 90%. To cling on to their dream, young people are being forced to turn to foreign medical schools for their studies, in places such as Bulgaria, but most of those who are rejected move into other scientific disciplines and are lost to the medical profession forever. If they have the hunger and the ability, we should be giving these students the opportunity to realise their dream of becoming a doctor.

There are clear economic advantages to training more doctors. Life sciences are set to be a major economic growth area in coming decades. To maintain our world-leading position, we need more medically trained people who can conduct the research and run the clinical trials.

Another benefit of training more doctors is for levelling up. The current distribution of medical schools around the country is poor. London has 22% of student places, but just 13% of doctors. That contributes to the increased difficulties for staffing in rural and coastal areas. We need new medical schools in places that are under-doctored—where the places are matters, as around 25% of students remain within 10 miles of their medical schools after graduating. The 2018 expansion capitalised on that knowledge and the new medical school in Sunderland is a fantastic case study. It recruits people from lower socioeconomic groups who are under-represented in medicine. Its graduates will help reduce the shortage of doctors in the north-east, a place where overseas recruitment has been ineffective, due to poor retention. A bonus is that a medical school contributes an estimated £20 million to the local economy.

The arguments are clear. We need to ensure that, as a country, the UK trains enough doctors for our own needs. Increasing training places will be good for the NHS and its patients, good for developing countries, good for the economy, good for the taxpayer, at least in the medium and long term, and good for our bright, young people who will be able to fulfil their dreams of a medical career. In short, it is the right thing to do.

We cannot waste any more time prevaricating on this issue. The medical students who started in 2018 will not be fully qualified GPs until 2028. For too long, we have kicked this issue down the road. Short-termism has been winning the day as we blindly increase our reliance on overseas recruitment. Far too often, we take the easy route and do not make the investments we need for the future. The UK must train enough doctors and other medical workers for our national needs. That is the only sustainable, long-term solution for the NHS.

[Several hon. Members rose—]

--- Later in debate ---

[Anthony Browne]

It has been a pleasure to take part in this debate under your chairmanship, Sir George. I thank my hon. Friends the Members for Truro and Falmouth (Cherilyn Mackrory), for Newton Abbot (Anne Marie Morris), for Redditch (Rachel Maclean), for Torbay (Kevin Foster), for Bracknell (James Sunderland), for Burnley (Antony Higginbotham), for Wantage (David Johnston), for South West Bedfordshire (Andrew Selous) and for Bolsover (Mark Fletcher), and the hon. Member for Strangford (Jim Shannon)—it is not a debate if he is not here—for their very constructive contributions.

There has been huge support from Members from across the House, including from Labour and the DUP, for increasing the number of training places for doctors, for all the reasons that I laid out and other Members raised in their contributions. I thought the social mobility point was incredibly well made. I am also delighted that so many people invited doctors to go and train in their constituencies, including down in Cornwall. I will pass that on to some of my trainee doctors.

I particularly welcome the Minister’s very constructive support. The Government are aware of this issue and want to do the right thing. The message I want to send the Government—the Department of Health and Social Care and the Treasury—is that there is huge political appetite and cross-party support for increasing the number of training places. We really need to do that for the sake of the NHS and the country. I am sure we will all be watching the developments over the coming months as the NHS develops its workforce plan. We fully support the Government’s aim to be as ambitious as possible.

Question put and agreed to.

Resolved,

That this House has considered the potential merits of training additional doctors.