Millennials– The Missing Piece in the NHS Workforce Puzzle?

UK healthcare is in the throes of a workforce crisis. There are 10,000 fewer doctors and over 50,000 fewer nurses than are required to run a safe and sustainable service. Multiple factors from removal of nursing bursaries, introduction of university fees, poor working conditions, under-resourcing of healthcare services, unmanageable workloads, learned helplessness of clinical risk and a culture of incivility or blame is driving the workforce of the future away from NHS. Several governmental agencies, arm’s length bodies and trade unions have been grappling with this challenge. A few solutions have been recommended under the new contract for junior doctors, reintroduction of support for nurses and expansion of medical school places, but some are yet to be implemented. NHS leaders continue to support bluesky thinking in terms of workforce innovations but tend to drag their feet when it comes to adoption. This reluctance by senior clinicians, managers and policy makers may be related to a lack of understanding of the values that drive the millennial generation that most younger healthcare workforce belong to. This article will explore the challenges and solutions from a generational perspective and offer an insight to guide future decision-making.


INTRODUCTION
I'm scared, I'm exhausted, and I hate being a doctor. 1 Over half of junior doctors in the United Kingdom (UK) do not continue their training straight after Foundation years, choosing a career break, flexibility in work schedules, in less than full time positions or switch specialities. 2,3 Thus leading to an expanding crisis in the safe staffing of hospital rotas. 4 Despite the considered re-design of medical training pathways, since the time of the Calman review 5 , postgraduate training is failing to persuade a significant proportion of junior doctors to commit to higher specialty training. Those in specialty training are delaying their transition into consultant posts, hence a large number of unfilled consultant vacancies persist, with notable geographical variation. As the healthcare workforce numbers are heavily regulated, the impact of this unpredictability on those remaining is huge, with an unsustainable burden of work falling onto the middle grade or senior doctors and nurses, whose recruitment is also becoming more challenging. 6

BAPIO
Patel_millennials_v4 vol13(1): 2 Added to this, the demand on primary, emergency or secondary care services is growing with an ageing population with complex health and social care needs. The UK public value the National Health Service (NHS) above all other issues in deciding the future governments, hence it has long been used as a campaigning tool in the agendas of political leaders. 7 There is a promise from successive governments of a better resourced, efficient, sustainable and safe NHS. However, the ground reality appears to be quite different. In the eyes of the junior doctors and nurses, the future of the NHS is seen as uncertain, and many of our doctors perceive working in the NHS as a sacrifice to the stability of their personal lives, their autonomy, health and well-being.
This article will explore the complex reasons behind these issues from the dual perspectives of a junior doctor (mid-way through higher specialist training), drawing on the narrative of peers who have left our workforce with a senior clinician and educator. We present here a wealth of knowledge gathered over several interviews, career conversations, mentor-mentee relationships to help understand the reasons behind the current workforce crisis. The authors offer recommendations for organisations in helping to turn this haemorrhaging of this complex workforce.

What determines junior doctors' career choices?
Numerous surveys identify the factors that junior doctors consider when making career choices. Here is a sample;

Organisational Factors -Working Conditions and Industrial Action
Junior doctors are regularly faced with the choice of moving home or commuting long distances whilst they rotate through clinical placements. Relationships with friends and family are difficult to maintain. The induction process is often inadequate, rotas under-staffed, managers less sympathetic to their conditions, education and training opportunities sub-optimal, culture hostile, and medical information technology (IT) systems across the UK are described as shambolic. 8 'I have personally moved house 9 times in the last 10 years of my training due to clinical placements in far-flung hospitals' The question uppermost in the minds of junior doctors was 'Is there any meaning to our role as doctors, if we can't do what is required to keep our patients safe?' The goodwill and dedication amongst the medical and nursing staff which had cushioned the impact of an increasing demand versus reducing resources on the NHS, was lost. Greater numbers of doctors are leaving fixed training posts for locum positions and the flexibility they offer, and to practice in Australia and Canada, with optimism for respect and a work life balance.
The long drawn out contract negotiations (2012-2016), the subsequent breakdown of trust between UK government and junior doctors led to in 2016, for the first time in 40 years, industrial action. Junior doctors walked out to protest the proposal of an imposition of a 7-day service without adequate investment in services or remuneration, transformation in working conditions or a safe working environment. 9 The deal finally agreed brought a £90 million investment for Junior Doctors over four years. 10 The deal included improvements in rest and safety entitlements, contracted less than full time (LTFT) rostering guidance, exception reporting for all Annual Review of Competency Progression (ARCP) or portfolio requirements and guaranteed annual pay uplift of 2% each year for the next four years. Amongst these organisational factors, the Academy of Medical Royal Colleges (AoMRC), General Medical Council (GMC) and Health Education England (HEE) have also made recommendations for robust educational supervision, career support, mentorship, flexibility and less than full time training, as well as supported return to practice under the scope of "improving junior doctors working lives" initiative.

Supportive Environment
The case of Hadiza Bawa-Garba cast the NHS workforce crisis in a harsh light. 12 The challenges of inadequate hospital staffing, compromised patient safety, institutional culture of bullying and blame were at the forefront of cases brought to public attention. These cases have empowered junior doctors to raise concerns about civility of interactions in the workplace and inaccessibility of senior support. Junior doctors often feel unable to share the responsibility or risks of their unsustainable workload with senior colleagues. The formal supervision of doctors who may be unfamiliar with organisational or departmental processes remains suboptimal. Junior doctors regularly face uncertainty about their roles, ways to escalate concerns and seeking support. Many doctors have only recently become aware of their Trust whistleblowing policies, following the landmark case of Dr Chris Day, an Intensive Care trainee who was discredited for raising safety concerns. 13 In practice, doctors doing their best in challenging circumstances are often expected to accept full professional accountability, and relationships with hospital and NHS managers are often strained. The attitudes of those who formally share this accountability prevent the implementation of the provisions agreed in the JDC negotiations at a local level. Foundation trainees hesitate to report patient safety issues, working beyond rostered hours and missing educational opportunities. On occasions, those who do raise their concerns in person, are offered vague feedback such as they should consider 'improving their efficiency and time management skills'. This form of discouragement from organisational leaders is a reflection of attitudes that are slow to change.

Individual Factors
Training programmes offering a 'choice of clinical placements and flexibility' are more attractive to junior doctors. The suggestion from the UK Government to 'conscript' newly trained doctors to the NHS for 4 years unless they repay part of their training costs has reinforced the widely held perception that UK medical training system remains inflexible and even coercive. The NHS is the fifth largest employer in the world, and is valued as a diverse working environment, with overseas doctors making up 25% of the workforce. In 2018, more international graduates registered with the GMC than UK graduates, and the NHS relies on the ability to readily recruit doctors from abroad. These doctors make a large contribution to the NHS, sharing their skills and knowledge, however governmental policies threaten their security of roles, impose increased costs for visas and access to NHS, restrictions on their families and hurdles in accessing specialist training and skills.
Junior doctors value job security after years of investment of time and incurring huge debts, yet are faced with uncertainty about the future of their careers, dependent on passing postgraduate exams, fulfilling demanding training requirements and annual revalidation criteria, as well as making a positive impression on their supervisors, whose mentoring they rely on. Doctors are more likely to apply for training programmes which foster better work life balance, and an encouraging and supportive environment. Female doctors, and those with young children often face discrimination for their perceived lack of commitment in less than full time posts, which are severely limited in availability. They often favour careers in General Practice due to the perceived predictability of workload, flexibility or work life balance it offers. 14 Although medicine overall remains a competitive career choice at undergraduate level, prospective candidates considering it may carry significant personal financial burdens, and the rising tuition fees and student debt may be a factor in the decline in applications. Socio-economically disadvantaged applicants often continue to work part time, alongside their undergraduate medical training, whilst worrying that they are unable to dedicate their time to demonstrate 'commitment to speciality', which is strongly favoured amongst recruiters and often correlates with success in postgraduate training applications. Perversely, the demands of a career in medicine has an adverse BAPIO Patel_millennials_v4 vol13(1): 4 impact on health and wellbeing. Medical training is associated with increased mental illness, work life imbalance and lack of job satisfaction. Female gender and younger age often are predictors of burnout in junior doctors. In particular, there remains a recruitment and retention crisis in Emergency and Acute Medicine, General Practice and Psychiatry, with increasing demand on these specialties.
Although HEE, Care Quality Commission (CQC) and GMC attach considerable value to league tables about the quality of services including education, most junior doctors make decisions about their training based on advice from their mentors and peers. This 'influencer culture', which is rooted in the experience, supervision and encouragement from senior colleagues acting as role models and mentors, has a larger impact on career choice than any formal reports of training surveys, which are less accessible and wholly irrelevant in practice. 15 Many junior doctors' career choices are strongly motivated by geographical reasons, with doctors prioritising proximity to friends and family, who provide a network of social support. One of the major challenges of the NHS is to attract doctors to accept positions in undersubscribed geographical areas. London has historically been oversubscribed and remains highly competitive, whereas unfilled vacancies persist in rural or less socioeconomically advantaged areas. The policy to redistribute training numbers from metropolitan cities to rural locations, in order to encourage junior doctors to develop local networks is unlikely to be successful. Cities are valued for their vibrant and dynamic culture, diversity, ease of travel, accessibility of recreational activities and overall lifestyle flexibility. The competitive nature of recruitment in major cities, particularly London, reinforces a sense of achievement and soughtafter opportunity, amongst successful applicants.

What are the Solutions?
Junior doctors are misunderstood millennials 16

Millennials value choice and flexibility.
The ability to choose their specialties, clinical placements and teams. The onetime suggestion from the UK government to 'conscript' 19 newly trained doctors to the NHS for 4 years unless they repay part of the cost of the £220,000 to train them had serious repercussions. This was suggested as a way to stem the tide of young doctors leaving the country for jobs in the antipodes. The key to keeping doctors in the country is to develop the right training environment for them, to be supported and valued rather than being coerced.
Millennials value diversity and are not afraid to embrace cultural differences openly. One of the previous government proposals was to charge overseas medical students the full cost of their training. This may be counterproductive and reduce international students interest in coming to England. There has been considerable correspondence about the large contribution that foreign doctors have made to the NHS. Overseas BAPIO Patel_millennials_v4 vol13(1): 5 doctors currently make up 25% of the workforce and in 2018, there were a greater number of international medical graduates registering with the GMC than UK graduates. They have added to the exchange of ideas, skill sets and knowledge between countries. This study formed part of a larger General Medical Council-funded study about the fairness of postgraduate medical training, which aimed to investigate the fairness of postgraduate training and the possible factors influencing differential attainment concerning International Medical Graduates (IMG) and Black and Minority Ethnic Graduates (BAME) , 20 and was conducted during the junior doctor contract dispute in late 2015.

Millennials value security.
Junior doctors are at a vulnerable phase of their career and their lives. Anxiety and uncertainty are common sentiments as their jobs are without security ad their future in the profession is dependent on passing postgraduate exams, displaying clinical efficiency, and making a suitable impression on their supervisors. Support, mentoring, encouragement, and mutual trust are key components in a good postgraduate training programme.
Millennials carry significant personal financial burdens. Although medicine remains competitive, rising tuition fees and higher student debt could be a major factor in the decline in applications. For many, student debt can exceed £80,000 (including maintenance) and medical graduates on an average salary are unlikely to repay their SLC (Student Loans Company) debt in full. 21

Millennials value work-life balance.
Rising workloads, worsening morale, the NHS pay cap which has seen doctors' pay fall by up to 17 per cent in recent years, and concerns around work life balance are likely factors contributing to doctors taking time out from training or leaving the NHS altogether. Postgraduate training is typically characterised by work-life imbalance. Long hours at work were typically supplemented with long commutes, out-of-hours revision and completion of log books and e-portfolio. Work-life imbalance is particularly severe for those with children and especially women who faced a lack of less-than-full-time positions and discriminatory attitudes. Female trainees frequently talked about having to choose a specialty they felt was more conducive to a work-life balance such as General Practice. 14 Millennials value time with friends and family. Trainees regularly are forced to move workplaces which could disrupt their personal lives and sometimes lead to separation from friends and family. This makes it challenging to cope with personal pressures, the stresses of which could then impinge on learning and training, while also leaving trainees with a lack of social support outside work to buffer against the considerable stresses of training. Low morale and harm to wellbeing result in some trainees feeling dehumanised. 3

Millennials value their personal health and wellbeing.
It is unsurprising that medical training is associated with mental health problems, with reviews concluding that lack of work-life balance, long hours, lack of job satisfaction, female sex and younger age are important predictors of burnout in doctors. There are significant concerns that already high levels of emotional exhaustion and burnout in doctors 22,23 will increase as a result of changes to the junior doctor contract in the UK and this will cause trainee doctors to leave the UK to work in other countries, causing significant problems for a health system already suffering a recruitment and retention crisis.
As a group, female doctors have been found to be vulnerable to burnout and studies have highlighted lack of work-life balance as the single most important precipitant of burnout in female doctors. A study from the USA found burnout rates among female doctors increased by 12-15% with each additional 5 hours they worked over the contracted weekly 40 hours and this correlated with women feeling less in control of their working environment. 24  Instead of focusing on healthcare in the traditional sense and treating medical issues as they arise, millennials gravitate towards wellness and prevention. They are also a lot more open to talking about mental health, which is a huge issue for the younger generation. This is down to the big impact that the relentless speed of change and the pressure of social media can have on them. In recent years, meditation and mindfulness have become increasingly popular and this is now becoming a significant industry that's attracting the younger generation. 22 Millennials learn in innovative ways: Young doctors' educational habits are changing rapidly. Doctors in training have to undertake competitive job applications and numerous assessments and examinations, while managing frequent job, role, team and hospital changes. More doctors than ever before are questioning the value of formal structured, unidimensional postgraduate education. Many millennials prefer to learn at their own pace. With the proliferation of digital learning resources, which can be very affordable, they can now achieve this. Also, the internet and connectivity has allowed them to reimagine how they work. They are able to experience a different level of productivity, if they are motivated to do so.

Conclusions
The NHS workforce crisis needs innovative solutions. Better understanding of the underlying values and motivations of the critically important millennial generation of doctors, nurses and other healthcare workers will help in creating the environment and conditions necessary to attract, retain and motivate the current junior workforce to keep their faith in the health service.