Posted by: Witch Doctor | November 13, 2007

Liam Donaldson said we need more doctors



A very long post. But no apologies.

In the very first posts in this blog, The Witch Doctor focused on the minutes below.

Note that Sir Liam Donaldson repeatedly says we need more doctors. He will not be drawn into the concept that there is an oversupply.

Remember James Johnson lost his job for spontaneously supporting him.

Consider that these two men might know much more about the government’s agenda than any other doctor in the land.

Note that The Royal College of Physicians, London, begs to differ regarding medical manpower.

Note also from yesterdays posting, The Royal College of Physicians, London, seems, with their introduction of “COMPETENT CLINICAL DECISION MAKERS” to have embraced “The Skills Escalator.”

Yes, they have embraced it with open arms even post MTAS/MMC.

Note they are also embracing the concept that “Hospital at Night” becomes “Hospital Morning Noon and Night.”

What the devil are they thinking about?

Are they thinking at all?

The Witch Doctor wonders what Sir Liam really thinks about The Royal College of Physicians.

On Thursday 15 November 2007 at 10.30am, Sir Liam Donaldson will give evidence on Modernising Medical Careers to a Health Committee in The Wilson Room, Portcullis House.

Here are the members of the committee:

Rt Hon Kevin Barron MP (Chairman) [L], Charlotte Atkins MP [L], Ronnie Campbell MP [L], Jim Dowd MP [L], Sandra Gidley MP [LD], Dr Doug Naysmith MP [L], Mike Penning MP [C], Mr Lee Scott MP [C], Dr Howard Stoate MP [L], Mr Robert Syms MP [C], Dr Richard Taylor MP [IND].

It will be interesting to hear whether Sir Liam has changed his views on medical manpower.

The Witch Doctor would like to be a fly on the wall at this session.

Look out my best broomstick, My Black Cat.

N.B. Note that there appears to have been an error in the original medical workforce figures submitted by NHS Employers (see 2 in text and at bottom of page).


“Q107 Chairman: In 1999 this Committee was advised that an oversupply of doctors was highly unlikely before the year 2020. We have received evidence from the NHS Employers that there is currently a 7% oversupply of doctors and that this will rise to 12% by 2009.[2] How did this occur and is this a desirable scenario?

Sir Liam Donaldson: My own view is that I do not really accept the assessment that there is an oversupply of doctors. Even if you look forward to those distant time spans that you have mentioned, we shall still be lower than the OECD average. When I came into post in 1998, we were above Turkey, but otherwise we were the lowest OECD country for doctors per head of population. We are still behind and I do not see ourselves as producing an excess of doctors at all, indeed with demographic trends, with the fact that we shall have a 70% female medical workforce in the next few years, with changes in technology, with greater specialisation, we are still going to need a lot of doctors.

Q108 Chairman: You heard the last couple of questions we had in the previous session. It is very difficult to relate to OECD levels and ratios about doctors to population as opposed to the actual needs of doctors within the system. Clearly this inquiry is going to be looking at the needs of different levels of clinical and others caring in the healthcare system. Is there no sort of optimum level within our system as opposed to saying that, if it is different to the OECD level or it is still lower than the OECD level, then there is still a need for doctors? Is that not quite the way we should be looking at it?

Sir Liam Donaldson: There are several benchmarks that you can choose. The most difficult benchmark is to predict future need which has always been unpredictable in the past. I have a fair amount, through representing the UK on the World Health Organisation, of insight into other healthcare systems and even at an impressionistic level, it is clear that many other healthcare systems are able to provide faster care than we do at the moment with a skilled competent doctor. We do pretty well and we are improving but the basic infrastructure of care in this country, which includes the number of doctors and nurses, is still expanding and it needs to expand further.

Q109 Chairman: You do not think with the expansion of medical schools that medical unemployment is inevitable?

Sir Liam Donaldson: No, I do not think so at all.

Q110 Chairman: Presumably at other grades as well, in terms of nursing and things like that.

Sir Liam Donaldson: I do not know so much about nursing, but as far as medicine is concerned, I do not think we shall see that. We have never seen it so far.

Q111 Chairman: Do you think that anybody who goes to medical school in this country and after very many years becomes a doctor, at whatever level, has a right to have a job within the system?

Sir Liam Donaldson: Yes, they do in the first instance and then, after that, it depends on how well they do their job and how well they perform and so on. But yes, the aim is to give every graduate a post to go into at the time of their qualification.

Q112 Chairman: Should that be under all circumstances?

Sir Liam Donaldson: Well, unless there are concerns about somebody’s competence, health, conduct and provided that they want to have a job. As you know there is a small number of medical students who, having graduated, go into other professions. Obviously there is a small proportion like that, but as far, for example, as this forthcoming summer is concerned, we expect to be able to put all our medical graduates into the first year of what is now called a foundation programme, which will take them through two years uninterrupted of basic medical education, which will be of a more educationally based nature than has been the case in previous years.

Q113 Chairman: If it was the case in this more transparent health service that the Government and the general population desire to know the costs of the National Health Service, as opposed to what it spent, if we are moving to payment by results, if I were running a trust and I had an option of either setting on two doctors directly from medical school, in their next phase of training as it were, and spending money from my budget to do that, as opposed to saying that I have a target to meet from my budget, maybe for elective surgery or something, and under those circumstances I have to spend the money on the patient and not on the doctor, would that be unacceptable?

Sir Liam Donaldson: There is a lot wrapped up in that question. Obviously, we want patients to be seen by skilled, competent doctors, but at the same time most chief executive officers of hospitals would know that if they do not invest in the future, then they will not have high quality doctors in the future. You do need both. These fears of expediency on the part of hospital chief executives are often talked about, but I have yet to meet one who would dilute the quality of training in their hospital, the quality of research and all the other things which eventually contribute to high quality patient care.

Mr Foster: I just wanted to talk about medical unemployment and to link it to the previous session where Debbie Mellor was talking about overseas graduates. In so far as there is medical unemployment in this country, that is where it is; it is for the several thousand who came here on spec without specific jobs hoping that they could find ones easily. That is where the medical unemployment lies. Because there were several stories last year about unemployment of UK graduates, the GMC conducted a study of the last three cohorts which found that the problem is absolutely tiny. Of the 2005 graduate cohort, there were six unemployed and four of those were not actually looking for jobs. Of the 2004 and 2003 graduate cohorts, there are about 20 and 30 in each case who are currently unemployed but generally that is because they are looking for a job that geographically suits them and have not been able to find it. Those numbers are absolutely tiny. So UK graduate medical unemployment is not really an issue.

Q114 Dr Stoate: The Royal College of Physicians have told us that the number of doctors receiving specialist training under Modernising Medical Careers is likely to exceed the number of posts ultimately available. Is that true or not?

Sir Liam Donaldson: We do not know what the number of specialist posts will be in 10 or 12 years’ time. The Royal College of Physicians have been very supportive of the Modernising Medical Careers programme, they are helping us in the planning, but, as you well know, there are great changes in medicine occurring all the time. For example, it takes 12 years to train a cardiac surgeon. Within the last five years, the developments in treatment of heart conditions, with the possibility of minimally invasive treatment, has meant that we are probably now going to have heart surgeons in excess of the numbers that we shall need. So a 12-year training programme and a five-year change in technology which has transformed the position for that particular specialty and I could give other examples. You have to keep these things constantly under review. If you settle on a figure now that you are definitely going to need in 12 years’ time, then we shall see problems in the planning of the specialist workforce.

Q115 Dr Stoate: Do you see a contradiction though between that and the answer you last gave. You could not see any realistic chance of unemployment in medical graduates and now you are saying that as we cannot possibly predict what we are going to need, then we may not need these graduates which we are currently training.

Sir Liam Donaldson: No, I am talking about the balance between specialties. There are 59 specialties. If we have 59 rigid boxes all with a number in them for 10 years’ time and then we sit back and do something else until the clock ticks round, then we shall have problems. We have to evaluate the need specialty by specialty, but on the whole, given the position internationally, the trends in the burden of disease, the growth of technology, the feminisation of the workforce, I think we shall need more doctors.

Q116 Dr Stoate: That is true, but if someone has done a specialist training programme, then that trains them to be a specialist in a particular area or field. If that is no longer required, then we may have an overall matching number of doctors, but if people with very specific higher training cannot then get a job in that specialty because it does not exist anymore, for example, then that is unemployment surely.

Sir Liam Donaldson: I do not think so. We need to take a more flexible approach. I cannot believe that the excess of cardiac surgeons that we would have, if we just simply sat back and waited, would mean all of those doctors were made redundant. They will be able to adapt the skills that they have gained in surgery and in the diagnosis of heart disease and treatment of heart disease into other specialties. For example, vascular surgery, operations on blood vessels, is a specialty which is going towards, not exactly disappearance but almost so. Now radiologists can push wires and tubes into those same blood vessels and do the treatment that would in the past have required a full-blown operation. We have to keep all of these things under review.

Q117 Dr Stoate: Just to go back to my first question, so the Royal College of Physicians is wrong, there will not be these specialist trained doctors who are going to have no jobs to go to. That is what they are saying to us and you are saying they are wrong.

Sir Liam Donaldson: If they are saying it in such black and white terms, then that is not right. If they are expressing a general concern that we need to get the specialty training right for the future, and they themselves have had ideas about redefining some of the specialties within the medicine, it is something that we need to work with them on and we do work with them. I do not mind them making provocative statements from time to time because that keeps us all on our toes.

Q118 Dr Stoate: They keep us amused as well. Just a final point. What will the impact of Modernising Medical Careers be on the non-training service posts, which the Royal College of Anaesthetists have called the so-called “failed doctor” grade? That was not my expression that was theirs. What do you see happening in that situation?

Sir Liam Donaldson: We shall probably see fewer of these posts which are really designed within local organisations to meet a service need because we are going to see an expansion of training posts following on from the medical school expansion. I do not like that description, and neither do you by the way you asked the question, but we do have to remember that there are many doctors today, for family reasons or work/life balance attitudes, who do not necessarily want to go on to become principals in general practice or consultants. For example, some of the most talented doctors in the country are in such posts in very specialised areas of practice. For example, I know of a radiologist who is very expert in the ultrasound diagnosis of certain conditions, who, although a staff grade, has cases referred to her from consultants because they regard her as the best opinion in a particular field. We must not regard these posts as posts which are not valuable and do not have a future; they do and they are very important.

Q119 Dr Taylor: Can we come on to the European Working Time Directive? Can you bring us up to date: In 2004 the aim was 58 hours. I cannot remember what happened about those European cases and time on-call counting within those hours. What is the state with that?

Mr Foster: In 2004 there was a reduction to 58 hours but the main impact of 2004 was that the rest aspects of the directive came into play, as interpreted by the SiMAP/Jaeger judgments, which are the two that you are referring to, which effectively meant that we could no longer staff hospitals with doctors who were resident on-call. Instead we had to move to a pattern of shift working. What has happened since is that there have been many, many attempts within the European Union to revise the Working Time Directive laws as they apply to rest and at this stage no agreement has yet been reached. There is a lot of consensus that SiMAP/Jaeger are having an unhelpful effect in some medical specialties and there is a common desire to overturn it, but it is intertwined with several other issues of the opt-out and so on. The next stage is a meeting in June under the current Austrian presidency which is going to hammer out yet another attempt to produce a compromise solution to it. At the moment we are still stuck with it. The next phase of the Working Time Directive is in 2009, when we have to reduce doctors’ and trainees’ working to 48 hours a week. That in itself will be a very, very big challenge, even more so if we still have not resolved the SiMAP/Jaeger issue. It underpins some of the comments that Sir Liam was making about workforce planning. Clearly, if you currently get 56 hours from a junior doctor and in future you get 48 hours, that drives a need for greater numbers.

2 NHS Employers have subsequently submitted a correction to its written evidence on this point. The evidence should have stated that there are currently 12% more Foundation level medical training posts available than there are medical students graduating in the UK each year. If current trends continue, this figure will fall to 7% by 2008-09, increasing the risk of an overall oversupply of medical graduates.

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The Witch Doctor – Link to a random page






  1. […] He even seemed to disagree with The College of Physicians. […]

  2. […] “The country needs more doctors.”. […]

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