comment‘ Bringing in doctors from abroad will incur other costs: are we sure that ‘we’re spending our money wisely? NO HOLDS BARRED Margaret McCartney Getting smart about GP retention A hundred million pounds is a lot of And some GPs want to return to money. NHS England has pledged to practice. Huge e! orts have been made spend as much as this on recruitment to streamline this process, but is it agency fees to bring in GPs from abroad. working? Over the past couple of years The aim is for extra GPs. Overseas I’ve watched as an outstandingly sharp, recruitment will make up a large portion knowledgeable doctor I know wanted to of this new wave of doctors. return to general practice a er a few years In the s, general practice in the out of the country. She’s faced obstacles NHS was saved by Indian and Pakistani despite having worked as a GP for several doctors, at a time when a third to a half years before she le . of UK medical graduates were emigrating The costs are prohibitive: she had to themselves. But these doctors were not self fund a trip to the GMC in London for always well cared for. They o en found themselves an identi" cation check. She then had to study for and in the most deprived parts of the country, frequently pass a multiple choice exam followed by a simulated without much support, discriminated against, and in surgery (" rst attempt is free; resits cost # and #$, the least competitive posts (but o en the hardest). How refundable at the end of the scheme). A er passing the can we be sure that we’ll do better now? exams, a supervised placement must be found amid the We really need to spend money on retaining the GPs myriad forms. A bursary is payable for this, but doctors we already have, particularly if we’re losing them at such have found it slow to appear and not reliable for paying a rate (more than fewer GPs in England in March the bills. In the meantime, the GMC fees roll on, and than in March ). indemnity fees must be paid up front. And practices A large group of GPs are retiring early. Many do must apply to be accredited to supervise returning GPs— so because they hate the Quality and Outcomes limiting the doctors’ availability and o en making them Framework (QOF), the current GP contractual hard to " nd. framework, appraisal, or the pressure of being on call More than a year a er trying to start back, the doctor while also consulting. Indemnity fees are soaring and I mentioned still isn’t working as a GP. Couldn’t some have been cited by GPs as a major reason for early of NHS England’s money be spent on sorting out the retirement. Surely, the money allocated to overseas numerous small bureaucracies that add up to an recruitment could be used to employ people who have insurmountable barrier? pledged to retire in the next decade. Some crises are unavoidable; some have been We could o! er moderated, abbreviated appraisal created through an obsession with process above and a fresh approach to QOF (we’ve abandoned it reasonable judgment. Expecting doctors to come from in Scotland, and the sky hasn’t fallen in). We could abroad and sort out our mess, while doctors go to waste o! er protected sessions to make working in later life here, is senseless. a realistic—even popular—option. Bringing in doctors Margaret McCartney is a general practitioner , Glasgow from abroad will incur other costs including training [email protected] and orientation: are we sure that we’re spending our Follow Margaret on Twitter, @mgtmccartney money wisely? Cite this as: BMJ !"#$;%&':j($(& the bmj | 28 October 2017 147 PERSONAL VIEW Kate Womersley , Katherine Ripullone Medicalschoolsshould prioritisenutrition andlifestyleeducation Students need to understand the role of their patients' diet in health promotion and disease prevention ould you expect General Medical Council requires Dietary UK, where nutrition education has a junior doctor qualifying medical students to interventions been notably lacking. It is not that to be con dent understand the role of diet in health are considered students don’t want to learn this giving basic advice promotion and disease prevention, to be outside material. If individual universities and care for the which includes being nutritionally of the had the courage to lead the way in W most common and fatal diseases? Of competent. Internationally, this evidence base, preventive nutrition, the majority course you would. NICE guidelines knowledge is lacking in medical unscientifically of medical students would be only state that a rst line intervention for training. Just % of US medical too keen to learn more about the “fluffy,” and diabetes, obesity, and high cholesterol schools provided the agreed subject. is to give “lifestyle advice”—but this minimum of hours of nutrition the domain of phrase is so vague that it is le up to education in . A recent study dietitians Image problem doctors and patients to de ne it and, of European medical schools was Nutrition science su# ers from an potentially, ignore it. slightly more optimistic, suggesting image problem in medical practice. In and , more than that nutrition education was a This starts with its subordination in % of American junior physicians requirement in !.% of institutions curriculums and qualifying exams. felt inadequately trained to counsel surveyed, with an average of ".! Dietary interventions are patients on diet and physical activity. hours of teaching. considered to be outside of the The picture is reportedly similar in This, however, has not been our evidence base, unscienti cally the UK. In Tomorrow’s Doctors, the experience at medical school in the “$ u# y,” and the domain of dietitians ACUTE PERSPECTIVE David Oliver Binarytruthsdon’thelphealthpolicydebate Stephen Hawking and Jeremy Hunt’s and sustaining services, we should Scotland and Sweden plan change for public argument in August over the sometimes focus on pragmatic populations of similar sizes to those future of the NHS and use of data solutions, whether or not they accord in STPs. led to some hard hitting claims and with our political ideology. On Black’s point about false strong accusations on both sides. For instance, England’s dichotomies, I would say that in In the a ermath of the spat the sustainability and transformation many areas of health policy two management consultant Stephen partnerships (STPs) could in theory apparently contradictory views Black wrote a provocative piece on deliver win-win bene ts by giving can each be partly true. The two the state of debate about the NHS. Two views more control and autonomy to views may be valid and perfectly Black’s thesis was that we can’t move may be local clinical teams and also more reconcilable if we are prepared to forward with constructive solutions equally valid permission for collaboration in consider both viewpoints when to the problems facing our health and and perfectly the interests of a population. They deciding how to proceed. care system if the debate is reduced reconcilable have been rightly criticised for The NHS is facing a major funding to falsely polarised, oversimpli ed being rushed, for overpromising gap long warned of by expert health arguments that are based on ideology savings, and for lacking clinical economists. It needs cash. But there rather than on pragmatism. engagement. It is not helpful to are further possible e& ciencies from I don’t always agree with Black’s discuss such localism only in tackling unwarranted variation, managerialist approach, but his terms of covert privatisation and fragmentation, and unproductive or argument deserves consideration. central government’s abdication of unevidenced areas of spending. And, If we are sincere about protecting accountability. Countries such as as with every system, we do need 148 28 October 2017 | the bmj Ongoing learning This undervaluation of nutritional BMJ OPINION Ara Darzi knowledge continues when it comes to professional expectations. It is Thereishugepotential rightly required that doctors stay toapplybehavioural up to date with the continuously economicsinhealth revised NICE guidelines in specialties Barely hours before Richard Thaler, the US such as oncology. This ongoing economist, was named as the winner of the learning is seen as a mark of Nobel prize for economics, Theresa May medicine’s progress. But changes in was announcing an opt out policy for nutritional guidance are considered organ donation taken directly from symptomatic of instability and lack of his writings. Such is the influence of scienti c certainty. Why in the case of the man credited as a founding father nutrition science is amendment not of behavioural economics, or “nudge expected, but rather belittled? theory,” now used by governments in rather than doctors. Medical Knowing exactly what we mean the UK and around the world. students rst hear about nutrition in by “improving patients’ diet and “My mantra is if you want to get biochemistry lectures about speci c lifestyle” would enable doctors to people to do something, make it easy,” Thaler told the Washington Post . metabolic pathways, abstracted focus on how they counsel patients, Whether donating organs or joining from disease mechanisms or patient personalised to comorbidities, pension schemes, making it easy means experiences. In later clinical years, individual cultures, and characters. making it the default decision. the details of healthy diets, ways to While the central aim should not The obverse is to make it difficult for assess malnutrition, or speci c food be to save money, if NHS doctors people to do the things you don’t want requirements for particular diseases become more e! ective and e" cient them to do.