The NHS has a junior doctor problem

Good afternoon. We live in extraordinary times. The geopolitical foundations of my lifetime — a cold war baby of 1972 who grew up in Thatcher’s Britain — are now subject to what feels like a sudden landslip in the transatlantic alliance. 

As a former correspondent based in India, China and Washington DC, I’ve reported on the growing pressure on the Pax Americana over the last 20 years — US dissatisfaction with European defence spending and the US pivot to the Asia-Pacific — but now it feels like a dam has burst.

If that’s correct, it will have profound implications for the UK — on both its foreign policy choices, but also domestic fallout on defence spending, the national finances, Whitehall budgets and the shape of domestic politics. The ‘State of Britain’ will do its best to keep up.

In the short term, those who cuddled up to Trump — Nigel Farage and Boris Johnson, most obviously — may soon find themselves with some explaining to do. Johnson’s early attempts after Trump blamed Ukraine for getting invaded by Russia speak of the contortions to come. 

Fixing the NHS

But with so much in flux, this week I wanted to explore a more concrete domestic policy issue that is core to Labour’s re-election plans: fixing the NHS, and specifically managing its workforce shortages. 

The NHS has become massively over-reliant on hiring doctors and nurses from overseas: in 2023 over two-thirds of new NHS recruits were non-UK graduates — up from under half in 2017 — according to the General Medical Council.

The last Conservative government took steps to increase domestic supply. The number of places to study medicine at UK universities expanded by more than a third since 2017 — from 7,660 then to 10,415 in the current academic year. 

But as we reported this week, that has rapidly caused training bottlenecks.

It turns out that ramming a load more medical and nursing students into the bottom of the NHS training pipeline, without a commensurate expansion in the upper sections of that pipeline is helping to cause a huge wastage of expensive talent.

Demoralised young doctors

The Nuffield Trust has calculated that fewer than three in five doctors (56 per cent) in ‘core training’ — that’s the part after you’ve completed medical school and two years foundation training — remained in the NHS in England eight years later.

As things stand now, around 8 per cent of doctors finishing foundation training didn’t receive an offer after applying for a speciality, according to Billy Palmer, the Nuffield Trust’s senior health policy fellow. 

That’s incredibly demoralising for young doctors who have already invested seven years of their lives in that career; and wasteful for the British state which now spends £327,000 on getting each student through med school.

That leads to the perverse situation described by third-year med student Eli Sassoon, on X on Tuesday, where his faculty was “encouraging students to look at careers outside of medicine” because of a lack of speciality training jobs.

As Sassoon told my colleague Laura Hughes, he’s now looking at the possibility of going to Australia: “It isn’t rocket science: there really is no point doubling the number of medical students if you can’t train those students afterwards.”

Workforce “refresh”

So without significant investment in training or a change of tack, the situation is going to get worse since the current NHS Workforce Plan (a 2023 scheme drawn up by the last government) has a target of 15,000 medical students by 2030-31. 

That’s 5,000 more in five years, entering a system that already can’t cope. That is not sustainable without change.

This week NHS England commissioned a review led by the national medical director Stephen Powis and chief medical officer Chris Whitty into postgraduate training for newly qualified medics. 

Labour also knows change is necessary. It is promising a “refresh” of that 2023 Workforce plan which, in the best traditions of recent Whitehall policymaking, was, to put it kindly, not very joined up. 

As the Nuffield Trust’s Palmer says: “The ‘plan’ seems to have been to put all eggs in the basket marked ‘lets just ramp it up, turn on the training taps’ and then hope for the best.” 

(This is a version on a theme: massively increase special educational needs entitlements, but without funding or facilities; pass laws to increase prison sentences, but don’t build enough prison places; promise a million homes for the Ox-Cam Arc, but ignore the lack of water and grid connections . . . I could go on.)

The new Labour government is trying to rationalise the approach when it comes to the NHS, deferring the Conservatives’ unfunded new hospital building programme to realistic levels given the state of public finances and looking to ‘refresh’ the NHS Workforce Plan.

Early indications from health secretary Wes Streeting are that there will be a shift to community health services and more GPs — another area of pent-up demand that requires a significant (but managed) domestic expansion programme.

Because per the Nuffield Trust, on average, nearly two GP training posts are required to get one fully-qualified, full-time-equivalent GP joiner as a result of dropout rates and increased flexible working requirements. 

But there is domestic demand — as is demonstrated by the number of UK students who can’t get places in UK med schools so go to European countries like Bulgaria to get their medical degrees before returning to the NHS. 

(That’s why I was away last week; you can read my report here. Anyone who likes bashing flaky ‘Gen Z’ kids should meet these students who were prepared to go and study in the Balkans for six years to realise their ambitions. They were very impressive.)

The key, however, if the UK is serious about growing its domestic talent pipeline, will be to manage that expansion across the entire training period which — from undergraduate to consultant doctor — can take 16 years. 

In a world where doctors increasingly want flexible working, the Nuffield Trust argues that may also mean more inventive ways of retaining NHS staff — from staggered student loan forgiveness to preregistration employment that offers a paid bridging year between finishing education and being a fully-registered clinician.

Because, as the Nuffield Trust argues, fixing the leaks in the pipe may be as impactful as continuing with a profligate increase in supply.

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Britain in numbers

The date for the EU-UK reset summit is now set for May 19, but as things stand expectations for the reboot of the relationship are fairly low — as the well-connected director of the Centre for European Reform think-tank Charles Grant sets out elegantly in a timely essay here. 

It still remains possible that the Trump situation catalyses the EU-UK reset discussion, but — for now at least — it remains on track to be a traditional, iterative Brussels third-country negotiation that all starts with fish and will deliver not a lot, rather slowly.

But this week’s chart showing the calamitous decline in UK goods exports since Brexit should give ministers serious pause for thought. Fixing exports is integral to addressing the UK growth problem and a deeper EU-UK reset is one obvious way to start to do this. 

Crunching the data, Anton Spisak, associate fellow at the CER, finds that UK ‘trade openness’ — the share of GDP from trade — has declined by 3.5 per cent since 2019. At the same time, trade openness across the EU — accounting for both intra- and extra-EU trade — has grown by 3 per cent over the same period.

His CER colleague John Springford warns that the picture looks even gloomier when you measure UK performance against countries most like us — so excluding the US and Germany — and including Australia, Canada and the Netherlands. 

“Trade intensity in countries whose trends most closely matched the UK’s before 2019 is about 10 per cent higher than before the pandemic. For an open economy dependent on trade for cheaper products, innovation and productivity growth, this is awful performance,” he says.

As Stephen Hunsaker at the UK in a Changing Europe observes, what analysts had hoped might be a temporary blip from Brexit is looking increasingly permanent, with the UK unable to return to pre-pandemic levels of trade intensity, while the rest of the G7 easily has. “This is what a slow puncture looks like, the UK unable to keep up with its competitors,” he adds rather bleakly.

This means the UK is entering the stormy waters of the Trump era with an incredibly weak recent trade performance. If the government is serious about growth, Spisak argues, it needs to address its looming trade problem.

“Restoring the UK’s trade openness should be at the core of the government’s growth agenda. This task is becoming more challenging every day, as global trade faces some of the most formidable new barriers in decades,” he adds.

But will a UK government in full ‘duck and cover’ mode against Reform — UK government officials have been warning the EU against any leaks on the coming reset ahead of May’s local elections — use the Trump situation as cover to be more ambitious about the EU reset?

No sign of that yet.

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