Who is accountable for the medical unemployment crisis?

The story of vaccination against human papillomavirus in teenage girls is one of success. Cervical cancer rates have dropped markedly in all socioeconomic groups (doi:10.1136/bmj-2023-077341).1 An equitable implementation plan has achieved equitable benefits (doi:10.1136/bmj.q996).2 A less good health story is the murky use of dubious medical labels to deflect from unlawful death. “Excited delirium,” a term used to explain George Floyd’s death in police custody, is now banned in California and Colorado and removed from police forms in the UK (doi:10.1136/bmj.q1047).3

What binds these extremes is the role of the leadership of health professionals and health systems (doi:10.1136/bmj.q1033 doi:10.1136/bmj.q1069)—the power to do good alongside culpability or complicity in harm. Health professionals need the right environment to best serve the public.45 Health systems cannot tackle health and wellbeing alone: other sectors must contribute. Leadership of a nation, of a health service, of a profession are central to meeting these challenges. Yet, failed leadership has only deepened the crises in health systems, in the cost of living, in the climate emergency, and in conflicts such as Gaza.

Many health systems face challenges of too much demand and an unsettled workforce, but the UK seems particularly troubled. Consider the alarming levels of food insecurity, worse than in similar countries, and you begin to see the truth in Michael Marmot’s verdict that Britain is a poor, sick country with a few rich, healthy people. Turning this around, whether in primary or secondary care, seems impossible without resolving the workforce crisis. Ten months ago, after years of delay, the government finally produced a workforce plan. Its release was accompanied by tremendous hubris (doi:10.1136/bmj.p1542): a 900 word statement supported by 43 ringing endorsements from medical leaders, somehow published without the full report available for scrutiny.6

Once the full report later emerged, holes in its logic and calculations became clear (doi:10.1136/bmj.p1515).7 A freedom of information request by one of our columnists, David Oliver, has shown the inadequacy of the risk assessment behind the report (doi:10.1136/bmj.q1068 doi:10.1136/bmj.q1073).89 Only a few weeks ago the National Audit Office questioned the modelling that went into the report’s staffing plans (doi:10.1136/bmj.q719).10

The quick failure of the workforce plan is self evident. In the face of rising demand and a struggling health system, doctors are now exposed to unemployment in three distinct situations: in progressing to specialty training, in finding jobs in general practice, and at the start of their medical careers (doi:10.1136/bmj.q1045 doi:10.1136/bmj.q1056).1112 Medicine, a career that offered professionalism, security, and a sense of purpose, is now one of industrial action, job insecurity, and loss of agency (doi:10.1136/bmj.q1072).13

The workforce plan has pitted doctors and physician associates against each other in a botched attempt to manage rising demand at the lowest cost (doi:10.1136/bmj.q1076 doi:10.1136/bmj.q1075).1415 The UK has too few full time equivalent doctors in primary care, but doctors are unemployed. Newly qualified doctors are underpaid, indebted, and disillusioned at the way their work, training, and careers are organised. Workforce fixes add to workload rather than reducing it. Staff suffer and so do patients. Although the number crunchers perpetuate the mirage of staff being added to the workforce, patient safety is being compromised.

This is an unprecedented case of professional destruction that compromises patient safety in one multilayered assault on the health system—but it is a failure without ownership. Who is willing to accept responsibility for this debacle? The 43 signatories applauding last year’s workforce plan? The people who wrote it? The government that set its boundaries? One thing these people have in common is that they are leaders. And, if nothing else, the failed workforce plan is a monumental failure of leadership.