A couple of days ago I was listening to the excellent New Statesman podcast which had a section on the NHS winter crisis. In amongst some very good points about why major system overhauls are not technically or politically feasible in the UK, they ended:
Stephen Bush: But there are multiple reasons that doctors are leaving to go to other countries many of which are to do with policy choices actively made by the government. But the policy choice not to tackle the housing crisis does mean that if you are in possession of a medical degree, the attraction of staying in London and not being able to buy anything other than a small flat within commutable distance to the hospital where you work quite antisocial hours to being able to buy a fairly large house –
Helen Lewis: yeah, and there’s been a great decline in hospital accommodation as well. I was talking to someone who’s got –
SB: in New Zealand or wherever.
HL: – yeah, exactly – two siblings who both are doctors and for various reasons have ended up practising abroad it is, that it is, very difficult with, and it’s the kind of the other side of globalisation, we talk about importing workers in lower-skilled industries to undercut us. We’ve got the problem at the other end which is we’ve got workers with high-level qualifications. It costs us a lot to train a doctor and then we’ve got a problem retaining them working in the NHS. Yeah again it’s another thing where just small things if you to talk to doctors who get to like only having a single bed in hospital accommodation. You know like they change around the way that on-call works that kind of stuff. You’re just slowly pissing off a group of people who have got a lot of individual power to go “huh, yeah bye. See you later”.
(That was totally not worth the effort to transcribe. But anyway…)
Helen Lewis is right – but lets talk specifics.
Ten years’ ago hospitals stopped providing accommodation to their F1s (Foundation Year 1 doctors – the first year of being a UK doctors). Arguably, this was a hangover from when we did 24 hour on-calls but it was still nice and to be honest, most F1s would rent privately rather than use often quite poor standard hospital digs.
The advent of a 12-hour shift pattern has obvious benefits – doing a 24 hour shift where you’re up the whole time is physically and mentally punishing. It was also accompanied by the European Working Time Directive which mandated an 11 hour gap between a 13 hour shifts and limited the number of hours one could work in the week.
Disseminated in time…
There are a couple of things to note, however. Firstly, the mandated time off doesn’t mean you’re not just generally tired. I did one, fairly quiet night shift on Friday night. Unexpectedly, I was still feeling quite tired 26 hours later.
When you do weekday (4 nights Mon night to Fri morning) or weekend nights (3 nights Fri night to Mon morning), at the end you spend two days jet lagged, trying to do as little as possible to recover. At 31, many of my colleagues have kids who don’t exactly understand this, let alone the other stresses and strains of home life.
Further, there’s an uncertainty which I’ve mentioned elsewhere in my blog. An acquaintance living in South Yorkshire told me that her husband, a paediatric surgeon, had been told with a week’s notice that he was moving to Newcastle for 2 years. They had at least one child, I think they may have two.
Yorkshire and the Humber Deanery is split into 3 schools, West Yorkshire (based around Leeds), South Yorkshire (Sheffield), and North and East (around Hull and York). The first two of these have historically filled their posts. Indeed, when I applied for anaesthetics, Sheffield and Leeds were competitive.
The difficulty was and is, fewer people apply for East Yorkshire. There has recently been a drop in the number of applications to Yorkshire and the Humber Deanery.
Because training posts were not being filled in the East, the deanery decided new applicants at an ST3 level (Specialty Trainee Year 3) would be expected to train across the deanery, with some reimbursement of travel and accommodation. There are two different ways to complete your first two years of anaesthetic training (Core Anaesthetic Training or the Acute Care Common Stem) but the point is, anaesthetists ready to move to the next stage were being asked to train, potentially, anywhere between Chesterfield and Scarborough.
Yes, we have been lucky in Sheffield; that all hospitals were commutable was a significant attraction of the school. When compared to the Northern Deanery (which includes hospitals in Carlisle and Middlesborough), the North of Scotland (an entire school of anaesthesia albeit limited to Aberdeen and Inverness from what I can tell) and Wales, Yorkshire and the Humber is not significantly bigger. It’s 186 miles from Rhyl to Cardiff, compared to the mere 100 from Chesterfield to Scarborough.
Your choices are to move every year; live in two places, coming back on weekends off; or commute long distances (possibly staying over on night shifts). None of these are straight-forward particularly for colleagues my age who have kids.
It takes 9 years of postgraduate training to be an anaesthetist, meaning you’ll be 32 before becoming a consultant and having a permanent contract. If you have the temerity to want to do research or an educational qualification, you have to increase that. In specialties such as cardiology or surgery, whilst not technically mandatory, to get a job you’ll need to time outside of training whether as research or a subspecialty fellowship. Completing training before having children is not always possible.
To an extent, none of this is unique to medicine. Soldiers earn less and are away from home longer. Other jobs mandate long commutes. Factory workers do night shifts for little pay. Nurses get paid less for an equally stressful job.
However, when one combines recurrent jet lag from night shifts, prolonged training before being able to settle down, the uncertainty of where one will be in 12 months, the inflexibility of training, the increase in retirement age, recent disputes with government over pay, incessant workplace assessments and exams, lack of rest facilities, and the possibility of dying on the way home from work, Helen Lewis’s “slowly pissing off [doctors]” encapsulates the factors that are chipping away at doctors’ numbers and doctors’ morale.
PS: for the non-medics, the phrase “disseminated in time and space” is a description used in the diagnosis of multiple sclerosis. This post has nothing to do with MS – the phrase just seemed apt and will ring a bell with medics.