The Ward Round: The trouble with training

New junior doctor strike dates have been announced, meaning thousands of medics – many just a week into their first foundation year – will walk out for four full days from Friday 11 August.

This is the fifth and final round of strike action during the British Medical Association’s current mandate (the Hospital Consultants and Specialists Association junior doctor members have already voted to continue with strike action until 2024), but it is unlikely to be the last.

The official NHS England data on the strike impact – although patchy – suggests close to 500,000 appointments have been postponed as a result of all four junior doctors’ strikes during March, April, June and July, amounting to an average of around 47,700 postponed daily appointments.

Meanwhile, elective waiting lists continue to rise, and NHS leaders and remaining staff have to find a way to cope with the added pressure.

August is always a challenging month in the NHS, or as one HSJ reader put it: August is “dangerous” at the best of times, and “…this is not the best of times”.

The government put out a testy statement, calling on the BMA to “put patients first”. NHS Providers’ director of policy and strategy Miriam Deakin said although trust leaders understood the “strength of feeling” amongst staff, every strike was adding more pressure to trusts’ capacity and budgets, calling on both sides of the dispute to find a solution fast.

Some have argued these strikes are, rather than solely about pay, the result of a long-running feeling of dissatisfaction and unhappiness among junior doctors at the conditions they work under.

In 2016 Health Education England established the “Enhancing Junior Doctors’ Working Lives” programme, which was designed to address a range of issues that had a “significant negative impact on the quality of life of doctors in postgraduate training”.

However, seven years later, for many junior doctors things have not improved. Throw in a pandemic, and more pressure than ever, and it’s understandable why they’re so angry.

Matt Church, HCSA junior doctor committee member and medical oncology registrar working in the north west, described a range of issues outside of pay that impact on morale and retention among the workforce.

Dr Church described how the requirement for doctors in training to rotate around different hospitals – often hours away from each other – has a huge impact on their wellbeing and personal lives.

“Sometimes we don’t get very much notice of where we’re going… or we’re told a certain hospital and then it turns out there was a mistake in the spreadsheet, and actually, you’re going to another hospital instead,” Dr Church said.

“It’s happened to me, and it’s happened to most of my colleagues. It seems like we’re treated as numbers on a spreadsheet, rather than as professionals and humans who have lives to manage.”

Dr Church also highlighted the poor training experience many junior doctors have, due to the increased pressure on NHS staffing and services. “I’m in a training programme, but I don’t always feel like I’m there for the training… I’m there to provide a service,” he said.

There are other financial aspects beyond pay too. Dr Church, and other junior doctors I’ve spoken to about working conditions, raised the expensive up-front exam fees that - unlike other professions - are not paid by their employer.

With each exam, or in some cases mandatory professional courses, the costs can rocket into the thousands along with the need to pay for medical indemnity insurance and General Medical Council fees, both of which are essential for any doctor to practise in the UK.

He also highlights poor working conditions which include no affordable or accessible car parking, no decent rest facilities, lack of food available overnight, lack of workspaces, and rules around taking leave while working on-call shifts (shifts that are worked in the hospital into the evening or over a weekend). “It makes me very tired, fighting this all the time,” Dr Church said.

He is, of course, keen to stress the main issue is pay, and other improvements must come with “a significant stride towards pay restoration”.

Surely a middle ground can be found by the unions and the government; some progress on pay in combination with substantial improvements made to the working lives of junior doctors. Failing, over many years, to make the NHS a better place to work has done nothing but fan the flames.

False optimism

On the subject of training, this week NHS England published fill rate figures for medical speciality training in England.

Minister of State for Health Will Quince described it as “another strong year for recruitment”, with “many different specialties… achieving close to 100 per cent fill rates”.

However, this is only half the story. The high fill rates for many specialities – acute care, anaesthetics, cardiology, dermatology – are good news, but there are also some concerning vacancies. For example, just half of medical oncology places were filled, less than 60 per cent of palliative medicine places and just 39 per cent of emergency medicine places are filled.

Also, the number of places available seems woeful. How can 62 obstetrics and gynaecology places available nationwide be enough, amid warnings of poor maternity care and growing gynaecology waiting lists, with women waiting years in pain? Or 92 gastroenterology places, considering the growing waiting list for diagnostic services?

The long-term workforce plan is disappointingly thin on plans for expanding speciality training beyond September 2024, pledging “1,000 more speciality training places for those areas that support wider NHS pressures and have the greatest pressures, such as elective recovery, urgent and acute care, maternity services and public health medicine”.

Based on this it looks like the bottleneck for speciality training is set to continue.