Doctor Training

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.

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.

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.

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.”

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.

I remind hon. Members that they should bob if they wish to be called in the debate. I call Jim Shannon.

It is a pleasure, Sir George, to speak in this debate, which I thank the hon. Member for South Cambridgeshire (Anthony Browne) for leading. I am happy to support the thrust of it and am pleased to be the Opposition Member speaking for it—that does not take away from others who probably wished to be here.

There is no doubt that we have faced years of NHS turmoil, and one of the main issues is a lack of sufficient staffing across all aspects of the NHS—nursing and doctors being the most prominent. There are countless reasons why we should train more doctors, but there are domestic issues hindering us from doing so. The hon. Gentleman referred to them, and I will address them from a Northern Ireland perspective. I am my party’s health spokesperson, so I am happy to speak on these issues.

I first want to put on the record—others will undoubtedly do the same—my thanks to the doctors of the NHS for all they do for our health in the United Kingdom of Great Britain and Northern Ireland. We are fortunate to have two fabulous universities in Northern Ireland: Queen’s University Belfast and Ulster University. I have spoken to many students who say there seem to be some issues with the number of places available for those who want to become doctors. Northern Ireland prides itself on the opportunities we offer to international students. We have an amazing scheme, but Queen’s can offer only about 100 places a year for medicine, and there is therefore a shortfall. If that could be increased, it would benefit us in Northern Ireland and people across the United Kingdom. The Minister is always responsive to our requests, so will he outline whether he has had any discussions with the Northern Ireland Assembly and the Department back home?

The hon. Gentleman referred to levelling up, and obviously I want Northern Ireland to be part of the levelling-up process. I welcome that the Government are committed to that, but sometimes we need to see the small print, so I ask the Minister to share some thoughts on that.

For the information of Members present, I do not intend initially to put a formal limit on speeches, but an advisory recommendation is that if everybody sticks to five minutes, we should be able to call everybody.

It is a pleasure to serve under your chairmanship, Sir George. I thank my hon. Friend the Member for South Cambridgeshire (Anthony Browne) for putting together an incredibly eloquent argument on an important subject. I also thank the many doctors and nurses who work in our NHS. I declare a small interest in that I worked in healthcare for a little while, in particular around general practice, which is the topic I will focus on.

My hon. Friend touched on some of the workforce and planning pressures we are facing. It is important to reflect on some of the trends he touched on, particularly the geographical disparities—the doctor deserts that he mentioned. It is also worth reflecting on the fact that we have 35% more doctors now than we did in 2010, yet we feel like we need so many more. There are some shifts underlying that, including more part-time working; yes, we are seeing some doctors return, and some doctors leave through work stresses, but working practices are changing. Our ageing society and the demographic challenge in healthcare is another real issue, but it is worth bearing in mind that the rest of the world is evolving. We use technology more and more, and the way in which we interact with each other is changing more and more, but we are not necessarily doing the same when it comes to healthcare. We are incredibly wedded to a bricks and mortar, 1980s-style of healthcare.

I want to touch on the question of what we want the doctors we are training to do. That may seem like a strange question, but doctors—particularly those in general practice—have become almost a catch-all for all the problems we are looking to solve. Without identifying what the different strands of healthcare can do, we are creating a crisis in almost every bit of it. General practice is not working, and in my opinion is a model that needs reforming almost entirely, but that is creating a huge strain on our hospital system. When it comes to training young people, it is worth bearing in mind that there are three times more applicants to study medicine than there are places available; it is not that people do not want to become doctors. I know my hon. Friend the Member for Wantage (David Johnston) is going to talk about the people who want to become doctors, so I will not steal his thunder, even though he has a really good stat that I like a lot.

I entirely agree that we need to train additional doctors; there is no question about that. The point has already been made that we need a diverse workforce and the creation of a number of new careers with shorter training periods. As my hon. Friend the Member for South Cambridgeshire (Anthony Browne) said, developing someone into a fully qualified GP, never mind a hospital consultant, is extremely time consuming. As my hon. Friend the Member for Bolsover (Mark Fletcher) said, we need to look at what we want our medically qualified practitioners to do and at how we can create the right career paths, some of which will be shorter and more specific to meet the needs that have been clearly demonstrated. There is no question but that various factors, including the growing population, covid and the ageing population, mean we face a real challenge.

I declare an interest because I represent a rural constituency in Devon and I have chaired the all-party parliamentary group for rural health and care. A couple of years ago, the APPG produced a report on the issue, looking at what needed to change. There are particular barriers in rural communities, compared to other areas. We have an increasingly ageing population with complex co-morbidities and a problem with attraction because, as has already been said, qualified doctors tend to want to stay where they were trained and not come to what they may see as a rural backwater. We also have a challenge finding accommodation for them, because our accommodation rates are very high compared to the level of income.

For me, one challenge is recognising the issues and then training and developing accordingly. We need more specifically oriented rural training opportunities and rural medical schools. There are one or two now, with the latest being in Lincoln, but the curriculum does not have adequate rural content or experience in all cases. It is abundantly clear, as demonstrated by the examples given by hon. Members, that that challenge will be met by recruiting people who live in rural areas. That may sound discriminatory but it would fill the national need for individuals to work in rural areas, and it has proved successful elsewhere.

It is upsetting for young British students who have the grades and desperately want to be doctors in a country that desperately needs them to be turned down. I nearly went through that as a parent; I have an interest because my eldest daughter is a junior doctor, and the agonies that she went through, and that we went through as parents, wondering whether she would get the grades and get a place, were awful. Many British families go through that, and it is simply not right when, as my hon. Friend the Member for South Cambridgeshire (Anthony Browne) has said, we have 30,000 doctors from India and 3,000 from Iraq. We should be able to train more.

I am encouraged that the Chancellor of the Exchequer has at last said that the Government will introduce a plan to ensure that the NHS has the workforce it requires to meet future need. The plan will be for the next five, 10 and 15 years, taking into account improvements in retention. That is absolutely right and, frankly, we should have backed it when he was Chair of the Health and Social Care Committee and made the same point. But better late than never—a sinner who repents and all that.

I want to talk mainly about general practice, but we have to get the training right for our doctors everywhere—in hospitals and in general practice. They work incredibly hard under huge stress. I will be delighted to visit the junior doctors’ mess at the Luton and Dunstable Hospital, as I had an invitation recently. I will listen very carefully to what is said there. Today I want to talk about general practice, and in particular about ensuring we have somewhere to train those young GPs as they go through their career. I was very upset to learn last Wednesday that my integrated care board—Bedfordshire, Luton and Milton Keynes—had to turn away eight trainee GPs, because there is nowhere for them go. That is an appalling situation.

Some 14,000 new homes are being built in my constituency. The NHS uses the measure of 2.4 people per home, which means 33,600 new residents, and we are really struggling to expand general practice. Last Wednesday, my integrated care board scrapped 30 of the 53 proposed expansions in primary care across its area—where we could have trained young GPs—for the lack of £2.95 million out of a £1.7 billion budget.

I remind Members that I will be calling speakers from the Front Benches at 10.30 am. To get everybody in, I will now impose a formal four-minute limit on speeches.

It is a pleasure to serve under your chairmanship, Sir George. We all agree that we need more doctors and I think we all welcome what the Government have done to increase the number of places and of medical schools. We had 2,671 trainees start in 2014 and we have had 4,000 start in the most recent year. That is all welcome. We know it takes time and costs money, in the region of £250,000 per person, but it is clear the Government want to get a grip on the problem.

The Government need to do that. I have had a huge population growth in my constituency and have seen a number of GP surgeries close their books. I have seen a surgery in Wallingford close its books, as have all the surgeries in Didcot. In some parts of the constituency we have helped a building expand to ease the problem, but here, without more doctors, it becomes difficult to serve the growing population.

Will the Minister comment on one thing that concerns me about the people we are training? I had an interesting conversation with one of my GP practices just a few weeks ago and I was told that a lot of the trainees now want a portfolio career. Of the cohort from which they have a trainee at the moment, only one intends to be a salaried GP. No one wants to be a partner; it is seen as the drudgery or boring part of the profession. People want to do some days as a locum in urgent care, specialist clinics and so on. I do not know the extent to which Government are looking at that and at how the profession is marketed. It seems to me that a salaried GP is a key pillar of the community, but, much like other people of their age, trainees are looking to do a range of different things, rather than the thing I believe we most need them to do at the moment.

My hon. Friend the Member for South Cambridgeshire (Anthony Browne) set out the challenges of training in superb detail and I am grateful to him for securing the debate. As my hon. Friend the Member for Bolsover (Mark Fletcher) commented, one key issue for me is about the make-up of the profession. Medicine is the most socially exclusive profession in the country. Only 6% of doctors come from a working-class background and someone is 24 times more likely to become a doctor if their parent is a doctor. If anyone wants to intervene and say that that reflects the country’s talent, they are welcome, but I simply do not believe it.