Abstract
Objectives
To assess the awareness, understanding and opinions of National Health Service (NHS) reforms among foundation year junior doctors.
Design
Participants completed a 16 question online survey, consisting of multiple-choice questions and questions with free text responses.
Setting
Foundation doctors were all working within one of the four London, Oxford or Severn foundation schools.
Participants
One hundred and two foundation year junior doctors.
Main outcome measures
Understanding and awareness of NHS reforms and health politics in general as assessed through six free text and multiple-choice answers to a set of basic factual questions. Opinions of the reforms were assessed through Likert scale (1–5) responses to seven questions.
Results
Basic understanding of health politics and NHS reforms was poor, even on issues affecting future training. A total of 17.7% could not name the health secretary, 66.7% did not know the budget of the NHS and 71.6% did not know who would be responsible for healthcare commissioning after the reforms. A total of 68.7% of respondents reported being interested in the reforms and 63.7% reported being concerned about their effect on their own career path. Despite this, 63.7% self-reported poor understanding of the NHS reforms and 90.2% felt they would value formal education on the current changes.
Conclusions
Despite being interested and concerned, junior doctors are surprisingly uninformed about the NHS reforms. Given the findings of this study, more work needs to be done to educate the current cohort of medical students and foundation year doctors and engage them with the changes taking place.
DECLARATIONS
No support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
None declared
Not applicable
SP
SP and OC contributed equally to the preparation of the data and manuscript. Decision to submit for publication was made by both authors.
Marcela Vizcaychipi
Introduction
The 2011 Health and Social Care Bill signalled the greatest change in UK healthcare since the creation of the National Health Service (NHS) in 1948. One of the key features of the proposals is allowing clinicians to be more involved in healthcare commissioning. Under the new system clinical commissioning groups, lead by general practitioners (GPs) with specialist hospital clinician input, will plan and buy healthcare services for a particular population. Should the reforms proceed as planned, current medical students and foundation year junior doctors will thus be central to this commissioning.
The reforms have been subject to extensive debate in the press, with many of the medical Royal Colleges expressing their reticence. Despite this, the opinion and understanding of the junior doctors who will be implementing the changes in the future has not been widely reviewed. Moreover, historical trends demonstrate reluctance on the part of trainee clinicians to immerse themselves in the politics and bureaucratic aspects of healthcare management. 1 However, education of medical students on the political and financial elements of medicine has been shown to alter opinion and significantly improve understanding. 2 Identifying gaps in knowledge and concerns among the current generation of trainees would allow additions to be made to educational programmes, which could benefit trainees in the future.
This survey-based study of foundation year doctors therefore aimed to establish basic understanding of NHS structure and the proposed reforms. We also sought to ascertain junior doctors’ opinions of the reforms including effects on patients and training and the need for formal training.
Method
Population
One hundred and twenty-five first and second year foundation doctors across six foundation schools (North West Thames Foundation School, North Central Thames Foundation School, North East Thames Foundation School, South Thames Foundation School, Oxford Foundation School and Severn Foundation School) were contacted between February and March 2012. Between them, a total of approximately 4000 Foundation Year 1 (FY1) and Foundation Year 2 (FY2) doctors are employed in these foundation schools. Doctors were contacted by email or social media networks. Those approached were randomly selected from a list of each authors’ relevant contacts. One hundred and two of those approached completed the online survey.
Questionnaire
An Internet-based survey consisting of 16 questions was used (Table 1). Information regarding each respondent's basic demographics, knowledge and opinions of health politics and proposed NHS reforms was collected. A combination of multiple choice, Likert scale and free text questions were used.
Table showing the 16 questions and possible answers included in a questionnaire completed by 102 Foundation Year Doctors regarding the NHS reforms
Analysis
Data from multiple choice questions are presented as absolute numbers with proportions and modal values where appropriate. Answers to free text questions were collated and the number of responses within each group counted.
Results
Survey population
One hundred and two (81.6% return rate) first and second year Foundation Year trainees completed the online survey. Trainees were distributed across six foundation schools, including London (North West Thames Foundation School, North Central Thames Foundation School, North East Thames Foundation School and South Thames Foundation School), Oxford Foundation School and Severn Foundation School.
Twenty-nine (28.4%) trainees were FY1 grade, while 73 (71.6%) were in their second year of foundation training. Of the cohort who answered the questionnaire, 49 (48.0%) were men and 18 (17.6%) former graduate-entry students.
Assessing factual knowledge
In order to establish understanding and knowledge of the NHS reforms, and the health system as a whole, six factual questions were included in the questionnaire. When asked to name the Secretary for Health at the time of survey, 84 (82.4%) correctly identified Andrew Lansley. Sixteen (15.7%) stated they did not know, or gave no answer, while two respondents (2.0%) gave an incorrect answer.
Those surveyed were asked to state the annual NHS budget. Responses ranged from £95 million to £800 billion per year. Thirty-four (33.3%) gave the correct answer of between £80 billion and £120 billion. Of the incorrect answers, 27 (26.5%) stated less than £80 billion, while two (2.0%) responded with a figure greater than £120 billion. The greatest proportion of respondents (39 [38.2%]) stated they did not know, or gave no answer.
Similarly, foundation year trainees were asked how much the NHS reforms are estimated to be costing. Answers ranged from £5 million to £100 billion. Again, the vast majority (49 [48.0%]) said they did not know or gave no answer. Thirteen (12.7%) correctly guessed between £4 billion and £6 billion. There were 33 (32.4%) answers less than £4 billion and seven (6.9%) more than £6 billion.
Trainees were asked to identify those who would be involved in healthcare commissioning after the reforms. Thirty (29.4%) correctly stated GPs with other parties, or as part of clinical commissioning groups. Forty-one (40.2%) thought GPs alone would be involved in commissioning, while two (2.0%) thought primary care trusts would take on this role. Twenty-eight (27.5%) stated they had no idea or returned no answer. Interestingly seven (6.9%) respondents made some reference to the involvement of private companies.
Using a multiple-choice question, respondents were asked which of five organizations would cease to exist after completion of the NHS reforms. Strategic health authorities (59 [57.8%]) and primary care trusts (65 [63.7%]) were correctly identified in the majority of responses. Conversely 19 (18.6%) responses included clinical commissioning groups as an answer, 10 (9.8%) clinical senates and two (2.0%) NICE. Five people (%) did not answer the question.
Finally those surveyed were asked whether regional deaneries in their current form would continue to oversee education and training for junior doctors. Seventy-six (74.5%) thought they would, while only 26 (25.5%) correctly recognized the current proposals include plans to de-centralize training.
Interest in the NHS reforms
Using Likert scales, trainees were asked to assess their own understanding, opinions and concerns regarding the proposed reforms. The majority of those surveyed reported they were interested (48 [47.1%]) or very interested (22 [21.6%]) in the NHS reforms (Figure 1). Conversely, well over half (Figure 2) stated they did not understand the reforms well (42 [41.2%]) or at all (23 [22.5%]).
Bar chart showing number of responses to question ‘How interested are you in the NHS reforms?’ among 102 foundation year trainees. Numbers above each bar represent total number of respondents
Bar chart showing number of responses to question ‘How well do you understand the NHS reforms?’ among 102 foundation year trainees. Numbers above each bar represent total number of respondents
Opinion of the reforms
Foundation trainees were asked whether they support the publicized NHS reforms. The largest proportion were apathetic, with 47 (46.1%) neither supporting nor resisting the reforms. Of the remaining responses, most were either against (31 [30.4%]) or strongly against (18 [17.6%]) the proposed changes.
Despite this, 49 (48.0%) and 21 (20.6%) were either concerned or very concerned respectively about the effect of the reforms on provision of patient care. Similarly, 36 (35.3%) were concerned and 29 (28.4%) were very concerned about the implications of the changes on their own career.
Desire for education
Trainees’ motivation to understand more about the NHS reforms was assessed. Ninety-two (90.2%) said they would value formal teaching about the proposed changes, with 47/102 (46.1%) expressing a strong desire for structured sessions. In addition, a total of 82 (80.4%) felt that education about NHS structure and health commissioning should form a part of medical student training.
Discussion
Though healthcare provision is highly political, apathy towards politics among medical students and doctors as compared with their peers has previously been observed. 1 The National Health Service in England is currently undergoing the most significant changes in its organization and operation since its conception in 1948. Coordination of patient care within this reformed NHS will fall largely at the feet of current junior doctors.
This study aimed to assess basic understanding and opinion of reforms to the NHS among current first and second year foundation trainee doctors. One hundred and two FY1 and FY2 doctors were surveyed, using a questionnaire which combined free text, multiple choice and Likert scale questions.
Knowledge about the NHS was surprisingly poor, with almost 18% of respondents unable to name the health secretary, while only one-third correctly stated the annual NHS budget. Similarly, basic understanding of the reforms such as approximate cost and key elements to the proposals (e.g. those who will commission health) was lacking. Encouragingly, almost 70% were at least aware that GPs would be playing a more integral role in the commissioning of healthcare services. Most worryingly almost three quarters of foundation doctors surveyed were unaware of significant changes that could affect their own training, namely that deaneries will no longer be responsible for coordinating education. This lack of understanding and knowledge may be a manifestation of the apathy towards health politics as described above. Moreover, for many juniors NHS management is remote from daily work on the wards. Many also seem unaware that the reforms will have any effect on training, hence the large number of incorrect answers.
Despite the above, the vast majority of foundation year doctors reported being interested in and concerned by the NHS reforms. In addition, they are aware of their lack of knowledge, with over 60% self-reporting poor understanding of the changes. This would seem to suggest that, though junior doctors recognize the importance of the reforms as a whole, motivation to delve into the issue further is low. Similarly, almost 50% of respondents were unsure of their opinion of the proposed changes, which almost certainly represents a combination of apathy and perceived lack of understanding. This is concerning given how significantly reforms will affect every junior doctor currently working in the NHS.
Seemingly in recognition of the above, the vast majority reported they would value formal teaching on the NHS reforms and that health politics should be a part of medical student education. Those surveyed therefore appear to be interested in and wanting a better understanding of the reforms, but would prefer teaching from others rather than undertaking their own research to reach these goals.
Despite the high return rate (81.6%), the number of junior doctors surveyed is low compared with the total number of foundation doctors currently working. Therefore, it may not be possible to generalize about all foundation year trainees across the UK. Moreover, respondents were from few foundation deaneries. The answers given may therefore be affected by local experiences and education. Another limitation is that, by virtue of being an online survey, people's responses are limited to the options available. Ideally, longer questionnaires or even face-to-face interviews which can assess understanding and opinions would be used.
Despite the limitations mentioned above, the group surveyed is likely to be representative of the foundation trainee population as a whole. The results and conclusions drawn are therefore still significant and relevant. Wider surveying, covering the whole foundation doctor cohort and assessing opinions and knowledge among medical students and more senior doctors is needed to complete the picture. Armed with this information, universities and foundation schools might be encouraged to amend future educational programs, including modules addressing health politics, finance and commissioning.
Conclusion
The NHS is changing, and arguably some of those who will be most affected by these changes are current junior doctors. This study has shown that, though foundation year trainees are interested in and concerned by NHS reforms, understanding of them is poor. Moreover, few seem to be motivated to address this themselves. This may be a current example of an attitude towards politics that has been reported historically. Given foundation year doctors will be implementing current health policy and arguably forming the policy of the future, it is essential to engage this population. It may be that improving health politics education – whether through formal teaching sessions for junior doctors or integration into medical student training – will be the only way in which this may occur.
Footnotes
Acknowledgements
Authors would like to thank Dr Neil Soni for his input and guidance in preparing this manuscript.