The future for medical specialists in the UK
Introduction. It seems very clear that the next few years will see very major changes take place in the way that medical services are provided in the UK, and in particular the way that medical specialists contract in the State and Private sectors to provide those services.
Training. The way in which specialists are trained is in a process of continual change. In the last five years, there have been at least three major revisions of the philosophy and practicalities of training programmes in all specialities which have resulted in a great deal of uncertainty for the majority of trainees. Currently, the implementation of the European Working Time directive, with working hours of no more than 48 hours in the week has left many training programmes with the impossible task of training specialists to the standard at which they can practice independently and safely within the time span assigned. How all this will be resolved remains to be seen, but it is hard to avoid the conclusion that at least some specialists will reach the end of their training without adequate experience to practice safely in the real world.
Changes in the National Health Service. After many years of sustained financial growth, the National Health Service will now find itself in a very different situation. Although politicians from all parties are claiming that they will protect NHS finance, it is difficult to see how they will be able to do so, and estimates of what will really happen suggest that there will be cuts in the amount of money available of anywhere between 10 and 30%. This will inevitably mean reductions in staffing levels, and although the number of managers is certain to fall, it would be foolish to assume that medical staffing levels will be maintained, and wise to anticipate that many posts at present "in the pipeline" will never materialise.
As more and more Trusts achieve Foundation status, there will be an increasing tendency to get the work of the hospital done more cheaply, and this will be achieved through employing non-consultant and non-training grade doctors and appropriately trained nurses to cover many of the activities currently performed by consultants. What will happen to the quality of the service is an open question.
As far as individual consultants are concerned, many are already feeling under a great deal of pressure exerted by Trusts unable to meet their financial targets. They are being asked to do more and more to produce "efficiencies" in their clinical work while being faced with the reality that their workloads are driven by external factors and are not controllable except by hospitals refusing to deal with the ill patients who present to the emergency departments.
In addition, as more services become consultant delivered, particularly in the acute specialities, the NHS will need to recognise that the Demands will not be sustainable for unlimited periods. What will emerge may well be a system where there are two or more stages of a consultant's career, with there being more emphasis on service provision at the beginning and on management of education at a later stage.
Changes in the private sector. Just as the worldwide recession has had a major impact on the NHS, the private sector has also been greatly affected. Generally, disposable incomes have fallen, and will remain lower for some considerable period. This means that people who could previously have afforded medical care in the private sector are now using the State system. The insurance companies are also feeling the effects and are seeking to maintain their profits as best they can. There is widespread alarm in the medical profession about the way that medical insurers are capping fees and beginning to refuse to recognise consultants who will not agree to lower their charges for their work.
Alliances are being formed by private hospital groups and the major insurers which are very powerful in dictating terms of employment to doctors and there is now little space in many places for individual negotiation outside their rigidly imposed structures.
Private hospitals are taking on more work from the National Health Service, particularly in areas such as elective orthopaedics and eye surgery. Although this does provide work for these hospitals, there are strict tariffs involved and there may not be a lot of profit for them in these arrangements.
Most of the private hospital groups are currently making great efforts to attract specialists of high quality who will bring profitable patients in to them, or to pay lower rates to competent non-consultants. There is probably a limit to the number of elective procedures that can be performed, but it seems unlikely that the private sector will in more than a very few hospitals seek to provide emergency as well as elective care.
Implications for career development. At the present time, the vast majority of doctors who go through the British training system assume that they will either end up as a hospital consultant or as a Principal in general practice. The realities of the job market are such that this will probably begin to change in the not too distant future. Already in general practice, there are a large number of doctors who have opted to be salaried GPs rather than take on the more lucrative but far more demanding role of full partnership.
Similarly, it is possible that many doctors in training will see the pressures and stresses experienced by their consultant colleagues, and decide that they will look for other ways of spending their working lives. Established consultants may opt to reduce the number of sessions they do within the National Health Service, the managerial component of their work and the amount of shift or night work that they are committed to. They may seek to renegotiate the contracts in a way that will find a balance for them between income and an acceptable lifestyle. Those who have high income as a priority may well reduce their number of National Health Service sessions so that they can enhance their earnings in the private sector.
In this new climate, it is vital for all doctors, even at an early stage of their careers, to formulate a realistic career plan and not to drift through training blindly assuming everything will be as it has always been. Those who do not will be at the mercy of a health care system that will become steadily more exploitative. Those who get ahead of the game, however, will find no lack of opportunity to create a fulfilling and successful professional life.