After a period of unmanaged mental illness about twenty years ago, I was removed from the GMC medical register. After this life event, I entered a coma and indeed became physically disabled. I have for various reasons found it difficult to return to full time clinical practise. You may ask why I have decided to write an article on ‘return to practise’ when I literally haven’t been a full time junior doctor since 2003. Actually, I’ve been procrastinating about writing the piece.
My situation concerns doctors who take unanticipated leave, due to personal health issues, or problems with colleagues, not people who plan to leave the NHS for a bit in an intended way. One thing which really annoys me is how politicians do not seem to understand the NHS workforce crisis, nor indeed have any practical plans to deal with it. I don’t deny that there is a retention crisis due to the NHS pensions arrangements. I am not focused on that, in that my contributions will be insufficient to secure my pension anyway. I think the apathy in solving the workforce crisis is illustrated by the sheer numbers of people who’ve been charged with the problem, often at very senior level, generously remunerated, but have not been successful one jot. It is a career limiting process potentially, but it could be a career defining or enhancing one. Like many things in medicine, like dementia or stroke, you probably don’t imagine that unemployment from the NHS will happen to you, but when it does you’ll finally understand why the matter matters.
Post pandemic, facilitating more registered medical doctors to work matters. This is obvious, because, not only do we need people to do the acute work and the elective procedures, we need to do other things such as risk reduction for illnesses and helping people lead as full a life as possible given mental or physical complications. But there is another issue which has always shocked me. That is, by not having a fair number of boots on the ground, life becomes much tougher for those who are there. There’s a clear difference between doing a job comfortably, and being too stressed to go even to the toilet without feeling guilty – or even taking any time off without incurring yet another rota gap. But it’s not just post pandemic due to COVID. Due to years of decline, social care is in a desperate situation, we have cut ourselves off from freedom of movement with the European Union, and we have the known known of an ageing population with ever increasing number and complexity of health needs.
No. The reasons why I have found it so hard to return to clinical practise should not be taken as ‘criticism’ of anyone or any statutory bodies, but should be used as inspiration as how to fix a broken system. The NHS is not fully privatised yet, and so the idea of a national plan is easier for the NHS than if healthcare were entirely privately owned and fragmented. It is theoretically possible for a central government to make the NHS workforce crisis as they can coordinate their response with the NHS social care crisis, or the housing crisis, or the economic and hyperinflation crisis, and so on. Whilst at a population level we need to know the ‘scale’ of the problem, at a personal level, unemployed doctors who want to work would benefit from careers advise. Of course not every unemployed doctor wants to return to the workforce, because of the unaddressed problem of low morale exacerbated by the hostile media coverage, burnout and so on.
It is impossible to plan numbers of boots on the ground without knowing the overall shape of how the NHS interacts with social care in providing an entire healthcare system. In other words, you can’t plan for the numbers of doctors in hospitals without planning for the numbers of district nurses in the community, and so on. The insidious and somewhat secretive yet acknowledged death of NHS dentistry should be a warning, like the ignorance of ‘Brexit’ and other “non-woke” issues, that ignoring an issue doesn’t in itself make it go away. When planning any strategy, there are known unknowns, known as ‘bounded rationality’ – take for example Brexit, or retiring BAME doctors, or doctors taking early retirement due to over punitive pension arrangements. But the problems in long term forecasting might be mitigated by shorter real-time forecasting.
There is clearly a financial disadvantage to NHS trusts hiring people to hire doctors at short notice through locum agencies. These doctors are able to charge a much higher rate, and do not especially like the lack of security at the expense of flexibility. Whilst doctors cannot plan, NHS Trusts cannot plan adequately. Speciality specialists, including physicians or GPs, could be asked how many doctors they currently need, even at a granular level. How they are funded cannot be kicked down the road indefinitely. Public services have become relied upon for doing more and more for less and less resources, and the various worms have turned. If a locum agency can warn me to keep my immunisations up to date, or my mandatory training (e.g. child abuse, ‘county lines’, safeguarding), or keep my registration up to date with an active license to practise, why cannot anyone else then? The GMC holds a central database of people on their medical register with a license to practise. They have revalidation and continuing medical education commitments. I had to sit a revalidation assessment for the GMC in 2019 in Manchester. Somebody should be mentoring all people on the register to tell them to keep their knowledge and skills up to date, even if they cannot absorb behaviours and skills because they are not in a paid regular job. This is a waste of talent otherwise, and the assets of the NHS are not just furniture or tangible.
For as long as I can remember it the informal advise from the GMC is that ‘it is not an employment agency’. I of course get that, but it does have a powerful say who is on their register or what motivates them. The GMC still has some way to earn the trust of BAME doctors on the register following high profile decisions such as Dr Hadiza Bawa-Garba. The recent furore over a teabag as a gift from the NHS has further identified about how the NHS approaches wellbeing. Years on, people do not generally see mindfulness and resilience training as the answer, but good care from colleagues. I for example became burnt out, living on my own in London, with no social life, with no regular educational supervision or pastoral care at all. As Liz Truss might say, ‘this is a disgrace’. I still have the wounds of my 2 months in a coma due to meningitis in 2007, but in fairness to me I have a license to practise on the GMC register, with full MRCP(UK) or membership of the Royal College of Physicians, a medical education training in progress, a PhD, plenty of post doc work including peer-reviewed papers and books, and years of being an unpaid carer with loads of experience about integrated care.
I was stuck off in 2007, but restored in 2014. Time lost for both me and my late parents. I can’t turn back the clock, but the best thing which would improve my wellbeing would be to have a paid job, a feeling of contributing to society, and a tangible effect of knowledge and skills to help the care and research for others. I have never wanted simply to join a locum agency after years away from the frontline, despite full registration, knowing that if I made a mistake I would be thrown to the wolves through under support – and I would go under with the legal and regulatory stress. This is why I think the GMC has a duty to solve the workforce crisis together with Health Education England – because the GMC is not only responsible for standards in ‘trainees’ but in all doctors, including education and training, and there is no more important a statutory goal than section 1 (1) of the Medical Act 1983 than to promote patient safety. To return to work, I need to be as confident as I can be about patient safety, working in teams, keeping my skills up to date. I should not be thrown to the wolves. As I have always been disabled since 2007, I am deserving of a statutory return to work as a reasonable adjustment under the Equality Act (2010). I have never had an opportunity to talk about this ‘need’ of mine, anticipating how to contribute to the workforce. I need to be valued before I return, not at the moment the NHS are forced to have me. I need to be supported and valued before I return. I need to know what mentoring and support services, including occupational health, before I return – even if they are patchy. And they need to be funded fairly.
The present situation is the result of years of neglect, and people who should have known better not asking people like me about their lived experiences of being thrown on the scrapheap rather prematurely. Hopefully things will finally change now. I am not holding my breath. You will of course notice that I have not offered much in the way of solutions. I don’t deny this is a very difficult problem, and one which deserves funding and a workstream of people solving the problem not as a part-time 3rd job. I think an extended induction or return to work scheme would really help. I think also that ‘returners’ really are yearning for a sense of ‘belonging’. This is what Prof Michael West and others have identified as part of their compassionate leadership approach. I entirely agree. Autonomy is another issue – all returners want to be confident, autonomous, independent practitioners but who can seek help and work effectively as part of a team. Returners like me are a not a ‘quick fix’. We are a neglected and scarce resource. If the NHS disappears, this debate will disappear too.
Shibley Rahman 