Should doctors owe the taxpayer for their training? (Medical Conscription)

Evgenia Galinskaya writes an excellent article on LinkedIn tackling the topic of Medical Conscription in the UK.

If you’ve been following UK healthcare news over the last few months, the latest idea by the Department of Health is to lock newly qualified doctors into working for the NHS for a period of time, potentially up to five years. This is to ensure that they “pay back” what the UK taxpayer has invested in them to train them. A figure of £230,000 has been cited as the cost of training a doctor. Doctors who quit working for the NHS before the end of that lock-in period will be required to pay back the cost of their training. I refer to this policy as “Medical Conscription”.

Evgenia makes the really important point which mainstream media has consistently failed to make: doctors are human beings and cannot be treated as simple assets like factory machinery where they can be sweated and expected to carry on working.

As a doctor myself who has stepped out part time, I acknowledge that I am biased in favour of doctors being allowed the freedom to choose a different career without penalty.

I can see how the argument “doctors who leave should pay back the £230k it costs to train them” has gained traction though. If the taxpayer has made an investment and doesn’t get a return, it is reasonable for them to be asked to be reimbursed.

However, if we are going to base a policy on a cold, hard economic figures, we need to be damn sure that the figures and assumptions behind them are correct. Let’s take a look at this argument using the same cold hard logic:

1) Where is the evidence for this £250k / £500k cost-per-doctor-trained figure?
Is this the cost to fund a student through medical school only? Does it take into account (i.e. subtract off) the tuition fees they pay?

Is it the cost of bringing a student from the start of medical school all the way through to a Consultant / GP? In which case, does it include the salary paid to the doctor? Has the out-of-pocket investment that a doctor makes in their “training” for courses / exams / registration / indemnity been subtracted from the total?

I am still yet to see a comprehensive fact-based breakdown of this figure. £230k seems to be a number plucked out of a Civil Servant’s arse much like the 6,000 deaths due to the “weekend-effect”. has explored this figure and found serious inconsistencies.

2) Has the economic benefit of a doctor been properly quantified?
This is so that we can work out the amount a departing doctors should pay back and the minimum conscription time.

How many thousands of pounds of economic benefit does a doctor deliver for each day they work? Has any attempt to quantify this been made? How much of this economic benefit translates to a taxpayer saving?

What about the differences between medical specialties? If I thrombolyse a stroke patient in the Emergency Department and give them a full neurological recovery such that they return to work rather than be fully dependent on care, how much is that worth in cold hard economic capital? What if that person is a CEO of a company employing thousands of people?

In other words: when does the tax payer “break-even” on a doctor?

3) Have the hidden economic benefits of a doctor been quantified?
Even if attempts to quantify the economic benefit of doctors have been made, have those attempts taken into account the extra hours of unpaid work doctors routinely do? What about all those audits and analyses taken in a doctor’s spare time which bubble up to NHS England / Department of Health stats, stuff they’d otherwise pay someone like PwC hundreds of thousands of pounds for?

4) At what point in history and across subjects do we apply this policy?
Why should it only apply to Medicine? Do other subjects and careers have a taxpayer funded component? What about Engineering students who do something else other than Engineering? What about PGCE students who decide not to go into teaching? What about “Mickey Mouse subject” degrees where there is no economic benefit to anyone from it?

The previous generation were given grants to go to university. Should those who ended up working in a career not relevant to their degree pay back those grants and the additional costs of educating them?

5) Should the taxpayer “owe” foreign countries who provide their doctors to the NHS?
About 35% of our NHS doctors went to medical school and did some of their post-graduate “training” overseas before coming to the UK to work for the NHS. Since the Medical Conscription policy is based entirely on the assumption that there is a public economic cost to training a doctor, surely by the same logic the UK should be heavily indebted to India / Pakistan / Nigeria / Eastern Europe who lose many of their doctors to the UK? Is the UK taxpayer happy to pick up that bill so that they can also fairly chase the UK doctors for their training costs?

It is not fair for the UK Government to “have their cake and eat it” by demanding minimum service for the costs of training their own doctors, yet nicking doctors from other countries without paying anything to those states.

So as you can see, even if we leave concepts of incentives / motivation / burnout completely out of it, the idea of charging doctors who leave for sunk costs requires a lot more analysis to work out what those sunk costs actually are.

Attracting Doctors:
Now let’s address the elephant in the room which Evgenia tackles – human motivation – in the context of economics:

While the Britain is an island, the UK is not the only country in the world. The NHS is not the only employer in the world. Medicine is not the only subject in the world.

If you give people the choice of:

1) getting £45k+ in student-loan debt to burn through 5-6 years of your life, to embark on a career where you’re paid £23k-£30k starting salary for a 48 hour week, to which you’ll be locked in for five years, where there are £1k of hidden costs per year in; or

2) doing a three year degree for £27k debt and get a job in financial services / law / management consulting for £38k starting salary, rapidly rising, with no lock-in; or,

3) not going to university and doing an apprenticeship where you’ll be paid a little and can earn £50k as a plumber / electrician; or

4) doing medicine overseas where the working conditions are better and there’s no financial liability (lock-in),

…where do you think the brightest and best will go? It won’t be option 1.

We’ve already seen Medicine degree places being offered through clearing in 2016 demonstrating that not enough bright students are interested in becoming doctors. And that’s before you add extra sticks like a five year medical conscription lock-in.

What will be the economic cost of filling the medical ranks with B-team people, if indeed you can fill them at all?

So what I am saying is that I don’t think we (and UK Gov) have any idea what the net cost / benefit to a taxpayer of a doctor is over the time of their career. Even if we did, the negative knock-on effects of medical conscription haven’t been considered by policy makers.

TL;DR: It’s a half-baked idea.


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