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Gold, incentives and meh

Newly trained doctors to be tied to NHS for four years, announces Hunt

Doctors will be required to work in the NHS for at least four years upon qualification as part of a £100m plan to make the NHS 'self sufficient' for doctor recruitment by the end of the next Parliament.

Health secretary Jeremy Hunt will unveil the new requirement alongside plans to expand medical school training places by a 'up to' a quarter by 2018, from a current cap set at just over 6,000 a year.

Speaking later today at the Conservative Party's annual conference, Mr Hunt will say that 'we need to prepare the NHS for the future' by 'doing something we have never done properly before: training enough doctors'.

He will say that this comes as currently a quarter of NHS doctors come from overseas.

The news comes as the Government is working towards recruiting 5,000 new GPs by 2020, but a Pulse analysis has suggested it will miss this target by more than half.

Mr Hunt will say his plans will make the NHS in England less reliant on doctors trained overseas and locums and ensure ‘all domestic students with the skills and capability’ to be a doctor have the chance to do so.

He will say: 'They do a fantastic job and we have been clear that we want EU nationals who are already here to be able to stay post-Brexit. But is it right to import doctors from poorer countries that need them whilst turning away bright home graduates desperate to study medicine?'

He will say that this is why he is announcing an expansion of training places, but that this will come with strings.

He will say: ‘From September 2018, we will train up to 1,500 more doctors every year, increasing the number of medical school places by up to a quarter. Of course it will take a number of years before those doctors qualify, but by the end of the next Parliament we will make the NHS self sufficient in doctors.

‘In order to ensure these reforms deliver for the taxpayer, the Government will also require for the first time that all those trained as doctors on the NHS will be required to work in the NHS for a minimum of four years after graduation.

'This mirrors the approach taken for those whose higher education was funded by the Armed Forces. It currently costs the taxpayer £220,000 to produce a graduate from medical school.'

The Government expects that expanding training will cost £100m by 2020/21 but that in the long run this will be offset by savings made from the locum bill which currently stands at £1.2bn a year.

Mr Hunt is also planning for international students in the UK to pay more towards their education and training.

Mr Hunt will says: 'Our medical schools have an outstanding international reputation, and these changes will in part be funded by charging international students for the totality of their training, including clinical placements which they do not currently pay for.'

It is not clear how the commitment to become self sufficient will be squared with NHS England’s commitment to recruit more GPs from international medical schools, revealed in NHS England board papers in July.

Pulse has reported as many as 600 European GPs are currently in the ‘pipeline’ to work in England, according to recruiters working with the NHS.

BMA chair Dr Mark Porter said the announcement 'falls far short of what is needed' and 'this initiative will not stop the NHS from needing to recruit overseas staff'.

He said: 'We know there are chronic staff shortages and rota gaps across the NHS, with major recruitment problems in areas such as emergency medicine and general practice.

'The Government must tackle the root causes of this workforce crisis and the reasons why so many UK-trained doctors are considering leaving the NHS rather than forcing doctors to stay in the health service. Demotivated, burnt-out doctors who don’t want to be in their jobs, will not be good for patients.”


Readers' comments (85)

  • And it should be a minimum of 8yrs of NHS service post-qualification, for those GPs who work part- time.

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  • Same mistake as the last increase in medical students.No mention of post graduate education.Most doctors who who go into training grades train for at least another four years before they are registers GPs etc.That is when we are attractive to the rest of the world.This man shows his ignorance of is remit yet again.I suppose there going to be a lot more clearing in medicine in future though!

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  • So someone is going to have to invest at least £100k to put themselves through medical scool and Mr Hunt is going to insist that they sign a dotted line or pay another £100k potentially? I think he is going to have to redefine the word altruism to make that a little more appealing.

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  • When does the rule forcing doctors to have to work in the NHS for 4 years start?
    Is it for the students currently in the system or any future ones?
    And what does he mean by saying "all those that train on the nhs will be required to work a minimum of 4 years for the NHS???"
    When I was a med student I never considered I worked ON the NHS at all.

    I can safely say that this will ensure that my children will NEVER follow in my medical footsteps!!!!! One was tempted but this will seal the deal for her going into another career. Thanks Jezza! She is an extremely bright girl and will now realise that she would be throwing her life away by becoming a doctor.

    P.s this would put not only UK students off studying in the UK but also overseas ones who fork out loads of money for the privalige.

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  • These threats of enforced servitude are not new, and they have extended to my profession, dentistry, as well for some time now.
    Now it seems they are intending to go ahead with this.i posted the following on a dental website, GDPUK, this morning, under the heading;
    The NHS Gulag.

    It is to be announced today that the NHS will train a further 1,500 doctors per annum in order to make up the shortfall expected as a result of Brexit.
    All doctors "trained" by the NHS will be obliged to work for the NHS for a minimum of 4 years.
    You can bet that this measure will be somehow extended to include dentists.
    The implications of this are quite startling, and unprecedented outside of armed forces, either here or anywhere else in the free world.
    Such moves are rumoured to have been considered before, but found to be in breach of EU human rights laws.
    This is an early example of the "Brexit dividend" at work.
    This is nothing other than state sponsored bonded servitude, another word for slavery..
    One has to ask how this is to be enforced?
    Are young doctors (and presumably dentists) not going to be allowed to emigrate, to places where their qualifications and abilities will be better rewarded?
    What will they do about female doctors who take career breaks to have children.
    Will they be forced back into the NHS Gulag when they return to work, regardless of their age and circumstances?
    Will this imposition not encourage an increase in the already depressingly high dropout rate from the profession, by both sexes.
    Will this not mean that "middle class" parents, including doctors and dentists, will now seriously discourage their children from studying medicine and dentistry?
    Will this deter the best and brightest youngsters from taking up medicine and dentistry in the first place?
    The answers to those last 4 questions are an enphatic "yes".
    One has to ask how this will be enforced.
    Will they prevent young doctors from taking holidays abroad in case they decide to "defect"?
    Will they install "doctor detectors" at airports, along with "doctor sniffer dogs" , trained to detect that lingering trace of formaldehyde from their days in the anatomy department?
    Will they withhold evidence of their qualifications in order to prevent them from being employed abroad?
    Will they imprison members of their families, or subject them to heavy fines, if they defect?
    Will they try to have them extradited back to the UK if they defect?
    Will they send in the SAS to either abduct them or 'take them out" if another country refuses to extradite them?
    Ok, some of what I have said is tongue in cheek, but not all of it.
    You can take a bet that the Whitehall mandarins and Tory MPs behind this would not be caught dead in the resulting NHS "sweatshops" staffed by the demoralised and underresourced victims of this policy of servitude.
    They will seek their treatment in selected "centres of excellence" conveniently located close to Parliament, or in the private sector, or worst of all abroad, in more enlightened countries where medical professionals are treated with the respect they deserve for their abilities, hard work and dedication.
    Such a policy would be a flagrant abuse of human rights.
    There are ways to legally create a binding contract of future employment in repayment for training, but these only exist as an alternative to self funding.
    I can only see the above plan being morally acceptable if there is both an alternative to self fund in the first instance, and a "buy out" clause for those who wish to depart the NHS.
    Anything else is a form of enforced servitude in contravention of all concepts of freedom of the individual since the abolition of slavery 2 centuries ago.

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  • Great idea!

    Let's impose a contract which forces people to work unsociable hours in disruptive manner and then impose a rule to force new graduates to take the contract.

    I know what will happen - any student with 1/2 a brain will stay clear off medicine and we'll end up those who couldn't get into media studies taking up medicine in future

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  • To work for 4 years will cover the F1 and F2 years and two of basic SHO training as far as I understand it. This will leave them free to go wherever they like then - none would have become GPs in that time so the part time dig would not apply. Doctors are most attractive to other countries when they have some experience so I cannot see this halting any exodus.

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  • If you get straight As most will go for some other job looking at the pay and working conditions. I do worry for the future if we end up like the lousy dentists of the past with grade Cs treating us.

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  • This is a tactic employed in the so called 3rd world countries to reduce brain drain. This is pathetic.

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  • Has anybody ever seen a breakdown of the oft cited "£220,000" cost of producing a doctor? Would be interesting to see what has been included, and whether this cost has been impacted by the increasing personal contributions to tuition fees. I've seen previous estimates include salary, which seems a fairly loaded way to inflate the perceived cost to the public.

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  • please please please. PULSE

    can you stop showing me that man's picture.

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  • Dear anonymous GP partner.
    I wrote, in my own name, in support of your profession.
    You slur on dentists is unfounded.
    The current requirement for most UK dental schools is a minimum of A*AA., including two science or maths subjects.
    When I trained in Ireland 35 years ago entry to dental school was at least as difficult as for medicine,, and it was well above grade Cs, even before recent grade inflation.
    Such childish remarks only help the DH to divide and conquer us all.
    We need to unite in our quest for justice for all healthcare professionals in the UK.
    Audoen Healy
    B Dent Sc, MGDS RCS Eng, FDS RCS Edin, FFGDP, DipImpDent RCS Eng.

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  • Committing for several years applies to people joining the armed forces so why shouldn't it apply to doctors? I had to do 6 years in the military and I cost less to train than a doctor does, so I have can't see what is the problem with 4 years? Are you so "precious"?

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  • Does he not realize that slavery was abolished a century ago? Unintelligible and incoherent - rather nonsensical ideas like this are going to discourage bright minds from becoming doctors. Unless.....and that is a BIG UNLESS, Mr Hunt is prepared to make medical education free in this country and then he may have some moral grounds to demand that young doctors dedicate some time to the NHS before going their own way.

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  • David Hogg

    Again Hunt is missing the point about the importance of retention. If we can only keep junior doctors in the UK because they're forced to, then we need to question how much society values having an enthused, motivated medical profession.

    Furthermore, I wonder if this will simply validate the decision of juniors to leave once they have 'done their NHS service'.

    It's time that we value NHS and care staff - across disciplines and pay grades - as a devalued and demotivated system will simply evaporate any remnants of goodwill. Given that goodwill (albeit dwindling) is a vital aspect of propping up a service under pressure, the NHS will just become more expensive, stretched and professional-lite than before.

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  • Practice manager: well founded points, but remind me, when in basic training as a recruit barely able to hold a providing NO service (I suspect you were probably a CMT, which is where most Armed Forces PMs start from), what did you pay for training? Nothing. What about when training after this? Some service, yes, but mostly training (and even funded to do degrees) but just like medical students who also provide a service on the wards - who pay for the honour. No one is precious.

    I would be delighted to rebrand medical students as apprentices who are paid during their clinical time, with rostered work rotas. Do that, then tie them to service. If they are providing free care while training (as many do) but pay £10000+ a year for the privilege, I fail to see what right the state has to tie them to anything.

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  • I don't think anyone "has" to do 6 years in the military; aren't press-gangs long gone?
    I'd like to see the breakdown of the £220k figure so often quoted. I'd also like the hours of study, ward-work while training, etc to be taken into account. The figure also needs to be put into context; how much to train lawyers, teachers or non-vocational graduates who enter banking or whatever (even politics). Surely the country benefits from having highly educated citizens. The NHS would certainly not benefit from forced employment regardless of suitability.

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  • Typical jeremy hunt - don't solve the problem of why newly trained docs are so keen to leave britain, just use the law to prevent it.

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  • Cobblers

    Why stop at medicine as someone has alluded to previously? The NHS is short of nurses, physios, midwives, I could go on. Post quali 4 years obligatory in the NHS. We know the NHS is dreadful to work for now but if most are compelled to work there what an awful environment!

    Why stop? Architects, Engineers, Teachers all compelled to work for the state.

    Eric Arthur Blair you visionary.

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  • Stick or carrot?
    Beat us up and make people stay for 4 years or change conditions to actually make people want to stay.
    Being forced into poor JD contracts and held to ransom for 4 years is certainly going to increase the emigration tide for people getting basic qualifications and experience, we may see a few FY2 and 3s float through GP in 8 or 9 years time but otherwise this is far from a solution!

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  • Dear Mr Healy, I (an ex-doctor who saw the writing on the wall a year or two ago) and many other doctors appreciate very much your comments. It is also very important to know how people in other professions, such as dentistry, are being treated to gauge what shockers are coming next.
    Thanks for your vision as it is important to see how other's perceive the medical situation.
    Keep us all in the loop please!
    I completely agree that we all need to stick together.

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  • The increase in places and the requirement to stay in the NHS should have been the case years ago. It will take till 2024 for us to see any benefit from the announcement today.

    A student at university studying film, or language or David Beckham or whatever degree they choose is paying around £10k a year for the privilege. It is not unique to medicine. When they come out of uni they are not guaranteed a job whereas medical students usually are, and a well paid job at that. (Average graduate starting salary is somewhere between £20-30k). So the costs of training doctors is paid by the tax-payer. It is not unreasonable that following their completion of training that they are required to stay in the NHS for just 4 years so that the tax-payer sees some of the benefit. In reality it is probably less than 12% of their career that they have to give to the NHS.

    For the partners so horrified by this ask yourself what you do in your practice. If a member of staff comes to you and says they want to train as an HCA do you agree to train them? Pay for their training? Reduce the amount they work currently to allow them to train. Take the burdens of costs knowing in the future you will reap the benefit. Then on the day they finish and can work as an HCA they give their notice and will be working elsewhere next month. Would you find that acceptable?

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  • Medical Students who joined the armed services get £10,000/yr and £45,000 lump sum on completion.
    Does Mr Hunt mean to do the same for those that go into the NHS?

    EX Ft Lt Pilot and GP

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  • PM @10.41
    Yes, entirely acceptable though not desirable. I would, however, ask why HCA prefers not to stay and address that rather than impose forced employment. This is the point - why is a "solution" like this even being considered?

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  • So - are we going to impose this also on engineering, science, and economics graduates - as the UK economy needs their expertise, and has contributed to the cost of their education?

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  • Having to work for the NHS for 4 years. Well most Docs probably do anyway. They will be so angry about this that they will be plotting their escape from day 1 of med school. They will take their 4 years experience and zip off to Oz etc. Comparing this idea to the armed forces is not a reasonable comparison . The armed forces are paid for one thing.
    If medical students are paid and have no tuition fees this would be reasonable. If you join the armed forces at 2nd MB you get paid .
    As others have said why pick on medics why not physics , nurses and indeed other degree subjects deemed to be of national interest.

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  • @ Rosalind Johnston Lots of employers in those sectors do impose that on their training. Some employers fund people through degrees and require the person to stay at the company for a period of time. The armed forces do it. A colleague was talking earlier that they know of a lawyer who is tied to their firm for a number of years as they funded their training. This is not new, just new to the NHS.

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  • BMA press briefing from 2013 on the cost of training doctors in the UK. the Doctors themselves will pay some of these costs by the look of it but the cost of training a GP is put at half a million.

    For those comparing it to physics or other graduates, does the UK tax payer pay anywhere near a comparable amount for those graduates?

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  • This would be fairer if medics dint have to pay tuition fees, and wern't saddled with 100k of debt after their studies.But this government is not fair.

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  • Opps forgot link @11:26

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  • @11:29 - broken link. You can't possibly think it's sensible to include their salary in the costs. You can't ever repay your 'debt to society' if you include salary as it's a never ending cycle - we might as well just work for free if we're going to play silly buggers and include that.

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  • Is he also planning to pay for the £9000 year university fees which the medical students have to pay? Didn't think so.

    And if not, then what moral grounds has he go to force the newly qualified doctors into a contract?!!

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  • Lets leave morale a side.

    If you are an A'level student, would you want to be tied to a job which can have contract imposed by the country at drop of a hat? And it's not even the best paid job compared to other profession.

    I certainly would not advice my daughter to go into medicine

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  • Medical families used to be the best advocates for studying medicine. Now all my medic friends and myself actively discourage our children to do the same. It is not a good or safe career anymore. I can see this changing in the next 10 years. Certainly with Hunt at the helm.

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  • You know, joe public do not have the faintest clue what is going to hit them in a few years! No NHS, medical tourism, private medicine (that is if there are any doctors left standing)......
    Jeremy is doing the most amazing job of destruction and once people do wake up, he will conventially have semi retired with a nice directorship in a private medical company and a gong.

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  • It is a Tory party headline. Will be Fish and Chip wrapper tomorrow
    There will be no new money, no new doctors and I suspect no binding of doctors to NHS, unless they do the same for ALL PAMS- They're too busy with BREXIT to do it

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  • I'm overwhelmed at the stout defence and utter rejection at this further attack the T&C of junior doctors by BMA this morning.

    Sorry, got 'over' and 'under' mixed up.

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  • I don't think I'd accept the reassurance that because doctors generally stay at least 4 years anyway, it's okay. If the principle were accepted, what's to prevent extensions to 5 years, 10 years or more +/- a ban on entering private practice?
    If the NHS wants to retain staff, it has to be like any other employer and offer acceptable terms and conditions. It's not that difficult, Mr Hunt - at least, it didn't used to be

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  • Dear Anonymous | GP registrar04 Oct 2016 9:07am

    You asked:

    "Has anybody ever seen a breakdown of the oft cited "£220,000" cost of producing a doctor?"

    Great question!

    I have corresponded with Lesley Curtis about this at PSSRU - which is funded by the government to look at these costs.

    Here is the latest set of data:

    The total is marginally higher than the costs quoted by the SoS at conference today.

    You can see that the "costs" include an element of tuition that is paid for by the students with a loan and then repaid to the taxpayer/student loanco anyway. (As you suspected) There is also a significant amount of £61,740 for living expenses/lost earning included in the total figure which are economic opportunity costs and NOT direct tax payer funded costs.

    The cost of clinical placement was surprisingly variable between universities and is supposed to be moving to a single tariff of around £33,000 per year. This only applies (pro rata) to clinical placements and the tariff for GP placements is usually lower. Tariff arrangements are set out here:

    It annoys me when people quote data that they do not understand. Politicians are notorious for doing this to meet their political aims

    But I have also heard HEE misquote this data to a Parliamentary Select Committee.

    It may be interesting for you to know that older versions of the PSSRU document had higher costs for GPs for Foundation Training than for consultants' foundation training!

    The figures for GPs and Consultants training costs assume UK undergraduate costs apply to all and do not allow for the costs of attrition. (That is the cost of the percentage that do not make it to consultant, which are significant percentages in some specialties.)

    All data is incorrect in some way. The experts in collecting data very rarely have any contextual understanding of the area that the data relates to.

    Great question though! I believe that the direct tax payer costs of UK undergraduate medical training that are not recovered through repayment of loans are much less than £200,000.

    Medical training is a common good. We need doctors and it is always better if they are trained doctors rather than untrained doctors!

    Some wastage and attrition is inevitable and we are net gainers from medical migration in both manpower and economic terms.

    There are many direct and indirect economic benefits to health services that discount the costs of training in other ways.

    I remember Don Berwick saying that the median health care spend in some US counties exceeds the median income! In an employer funded medical insurance system, medical insurance is a significant burden of employing someone.

    The NHS is a bargain for UK PLC and gives our employers/industry a competitive edge in a global economy, because approaching health as a common good means that per capita costs are reasonably low in return for a comprehensive, reasonable quality service.

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  • @1:52pm Thank you so much! That's a gem of a reply, I've been struggling to find anything useful. Really appreciated.

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  • @1:52 - also, any thoughts about the fact that a large chunk of that cost is towards clinical placement, and this money often gets fed back into departments of the NHS? ie a local Derm department getting a large chunk of money for having students, which then will often get diverted back into the cost of running the department as a whole, benefiting patients?

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  • medical students are effectively funding the NHS?
    Quelle suprise as how many juniors and others already fund the NHS by working excess hours for free.
    All Jeremy has done is to legalise it.

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  • I think we're getting mired in the wrong level of debate here. If the NHS suddenly has to shackle it's staff vs the not-so-distant times when (for instance) we used to have to think how to oblige 70+yr old GPs to retire, something has become very wrong with the way we are treating our doctors. As a tax-payer and future dependent, I find that worrying.

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  • Jeremy would make a good replacement as boss of Sports Direct. Perhaps he should be dragged before the select committee and asked to explain his approach to managing his employees in a fair and reasonable manner.

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  • Well spoken Audoen Healy.
    You've hit the nail on the head!
    The future is bleak indeed!

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  • Anonymous | GP registrar04 Oct 2016 2:55pm

    "@1:52 - also, any thoughts about the fact that a large chunk of that cost is towards clinical placement, and this money often gets fed back into departments of the NHS?"


    I think this is what I meant about direct benefit to health services that discount the costs of training. You can't just look at the costs without counting the benefits.

    In the old days when I had access to these things, I noted that our nearest large teaching hospital trust's second biggest source of funding after the local PCT, was the workforce and education directorate of the SHA.

    One of the reasons why Tariff had to be phased in was to avoid destabilising large trusts.

    Shame that decisions are made about removal of MPIG, outsourcing of payments agency, removal of PMS.....all without such worries about destabilising primary care.

    Our blessing and our curse is that we are many, diverse, distributed small scale providers of mission critical, large scale services.

    Because of this and a shameful lack of data about demand, they don't know that they've broken us until the ambulances are full, the A&Es are breaching and there are no secondary care beds because of delayed transfers of care.

    GPs are the capacitors in the system and we are currently super saturated in a working day that is unsustainably "decision dense" for too many of us.

    The recognition is slowly dawning up there, but we need action not words. Unfortunately our SoS has broken the "psychological contract" for many and he is doing himself no favours with this rhetoric, however well it goes down at conference.

    Fortunately I still meet many good, determined, brave and incredibly hard working GPs, who having invested a career in serving a local community are determined not to give up. We need to support them and people like you who are the future and our cavalry.

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  • @3:56 - Thanks for your insights.

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  • Its delightful for Mr Hunt to make sweeping statements like this, but let's look at the practicalities from an individual perspective, and the risks involved.

    Medicine is a stressful career. We force 16 year olds to choose to do it. Many haven't yet formed a basic understanding of what is involved. A considerable number, while bright, discover during the course that the strains of dealing with death and severe illness you aren't cut out to deal with this stress. It makes you ill.

    Very ill. In fact, mentally ill. Depressed. Perhaps even suicidal.

    We are then forcing some young people, to commit to a service that will, through no fault of their own, harm their health. And may even contribute to their early death (via suicide). Who are unhappy, and not able to perform - to the benefit of patients.

    Occupational health services are going to be swamped with young doctors, desperate to serve their time to avoid paying a fine, whose health is harmed as a result.

    Law suits will result. Families will be sueing the government for the deaths of their young ones.

    Let us not forget that medicine is a stressful career. We have one of the highest suicide rates of any profession. Not everyone can cope, and they don't know they can cope until they try it. They should not be forced to risk their health for politically catchy soundbites.

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  • Means the government will be able to make the first 4 years as crap as they like, slash wages, insist everyone works 20 hours a day a label it ' core hours', impose a requirement to sing a song in paise of our dear leader Chairman Hunt every morning. Want to leave? Want to leave?? You owe the government £200,000. You can't leave. The government owns you.

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  • Its just a further sign that the compact between doctors and patients is eroding as the NHS shreds.
    This is a horrible time for doctors as we transition to a US style system. Unless Corbyn is correct and we are close to the historic collapse of Capitalism the market is eventually going to sweep away this loved wreck.Stop clinging to it in your head- the game is over.

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