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28 June 2013
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Time for a new employment compact

Three years ago tomorrow I went back to Medical School. As a Quality Improvement Fellow funded by the Health Foundation I spent six weeks at a summer school in clinical effectiveness, part of a Masters Course in Public Health. On 5 July 2010 I sat in a traditional medical school lecture theatre at Harvard surrounded by unfamiliarity.

Many students were working as residents at the Boston Hospitals and at summer school as part of their program. Some left early each day to do a shift on call. Others were still medical students and adding an MPH (Masters in Public Health) to their qualifications. Some of us were foreigners or mature students or both, some sponsored by foundations or self- funded out of personal wish for improvement  We all worked together on statistics, project design, epidemiology homework and course work presentations. I learnt a lot more than clinical effectiveness.

Today’s students multi task with numerous windows open on their laptops, emails (often in two different languages) , Google entries for the lecturer or his topic to check the facts and prompt challenging questions, lecture notes and your own amendments, stock market trends, and in our case the 2010 World Cup! They can manage a lot of inputs while producing output. Generation Y have different approaches to work, life and their personal direction over both.

Medical School in the US has always resulted in debt ($45,000 fees for each of the four years at Harvard Medical School). This is on top of three years of college fees. In 2009 I understand not one graduate from Harvard Medical School took up a family medicine residency program (the UK equivalent of primary care). The economics make it less attractive to take on more static and limited roles compared with the potential opportunities as specialists. Personal career choices for younger professionals are not immune to market forces or generational shifts of attitude.

So on the 65th birthday of the NHS I am asking if the workforce model on which the NHS is built due for retirement. Is a centrally organised workforce and long term employment of professionals because it is a monopoly provider viable any longer?

I say this because I sense a perfect storm developing. In the global market for doctors a graduate may rightly sense they can potentially work anywhere. Research tells us that academically able ‘Generation Y’  (anyone born since 1985) look for amongst other things; fulfilment from a flexible workplace, work life balance with less work taken home, good relationships with their employer that bring opportunity and coaching. Is this possible with our centralised bureaucracy and current hospital and primary care employment structures? A comprehensive report by Institute for Leadership and Management at Ashridge Business School; Great Expectations, managing generation Y, includes quotes that should worry us.

‘Graduates are more independent than before and they are more enthusiastic. This can create conflicts between the graduate and the manager’.

’Graduates tend to be less engaged with the company and value more their work-life balance and personal interests. Their loyalty and commitment isn’t as strong as the previous generation’

In the whole life plans of a medical professional each year’s earnings may seem more critical in reducing the burden of debt that newly qualified doctors in the UK now need to consider(potentially some £100,000). Pensions may have been an in built retention mechanism in the past but are unlikely to be seen as secure by Generation Y, their future is safer in their hands not that of the system or the politicians.

In a recent seminar with doctors in training 13 out of 30 F2 doctors declared their next posts as ‘abroad’ for at least a year. This desire to see the world is not new but what are we doing to pull them back?

7 out of 15 senior registrars in a surgical speciality in one Region alone have left the UK system over the last five years to take up consultant jobs abroad. How did this happen, poor workforce planning or failure to give opportunity to the most able and adventurous?

Foundation doctors can experience chaos and lack of inclusion as they rotate from ward to ward. 2 of the same 30 I met recently have deliberately chosen non-clinical careers as a more satisfactory balance of work, life and intellectual ability. Will they ever come back into clinical medicine?

In big bureaucracies those in charge can easily miss the alarms that are sounding far away in the system they control. At the same time they generate so much of their own paper work they can fail to read the news outside their own fiefdom. Healthcare is a business that can learn from other businesses, it forgets this continuously. Where the forces of natural selection on organisational models and products are far less forgiving change happens fast. It is survival of the fittest. Few organisations in the business world have lasted 65 years. We should read what non heath businesses are saying as they adapt to the competition for talent and the pressures of the internet educated, globally comfortable, professionals with a clear sense of what they want from their career.

Organisations recognise that they cannot survive in the fast changing economy with ‘career for life’ workforce contracts (Harvard Business Review June 2013 Tours of Duty- the new employer- employee contract). Enabling staff to harvest ideas from without and expect and support them to make them happen in your organisation is seen as a retention tool.

Accepting some staff will choose to move on and develop in a competitor organisation is seen as the development of an alumni network not a loss or a failure (for them or the organisation). Including and developing staff in the design and development of innovations provides an attractive environment for staff who might otherwise seek that opportunity somewhere else.

Keeping your top talent is necessary for today’s success and must be a strategic objective for surviving tomorrow.  I am not clear if this is gaining traction due to it matching the aspirations of generation Y or due to the pace of business in a globally competitive world but there is a possible synergy with the global trade in healthcare professionals

I am of the view that we had better change the way we employ our medical staff. Doctors in training need to be clearly supported and organised to change and improve the systems in which they work (Quality Improvement education and projects for all)  Consultants need to be clearly developed as leaders and agents for transforming care maximising all the abilities (investment in them as leaders from day one).

With some of the top academic talent in the country graduating from medical school we need to ask what organisational model will deliver all their potential not just some of it. Neither the system nor the individual seems to want ‘a job for life’ approach as delivery models won’t last twenty five years of a consultant career. Yet nor can we afford to have an ‘every man for himself’ employment contract where mobility across the globe generates uncertainty in cost and availability.

We need a sea change, from an employment contract to an employment compact, one that continuously rebuilds employee commitment to do the work and ‘work on the work’ each day so as to improve themselves and the system in which they are employed.

Job plans, appraisal and revalidation hardly get us off the starting block. Doctors in training are a key part of the system today what would build their clinical and healthcare delivery knowledge in parallel? Should we have a five year contract for all career grade doctors to provoke pace, innovation and improvement? What would be wrong with consultant/ general practitioner appointments based at Regional not hospital or practice level to enable system wide change and the easier redesign of models of delivery? Of course the short answer is ‘continual reorganisation of the NHS makes this impossible’. Now therein lies another blog...

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