Want to jump across the pond to enjoy an afternoon tea with scones and clotted cream?
Here is a three-part series exploring the UK medical system. Part one will explore the UK healthcare system & culture, part two will explore the UK medical education structure, and part three will explore the nitty gritty of transitioning to practice medicine in the UK.
The National Health Service (NHS)
The National Health Service (NHS) is the publicly funded healthcare system of the United Kingdom encompassing NHS England, NHS Scotland, NHS Wales, and Health and Social Care in Ireland.
The NHS was formed after World War II to address the health disparities that prevented many poor people from accessing preventive or emergency care. The government developed a system to provide care for all. It passed into law without the support of doctors who were concerned their salaries would drop.
It is not a perfect system. Only people who clinically need specialized care receive it, and only when it’s needed. If socialized healthcare is not your cup of tea, practicing medicine in the UK may not be a good fit. Private work is available to supplement an NHS position – though it is not a career unto itself. In popular areas, private work is very competitive.
In the UK, healthcare provision is viewed on a national and local level. Broad decisions about healthcare, what care is needed, how much, and where to provide it, is determined by the UK government (health minister and supporting staff) with input from the Royal Colleges and practicing clinicians.
Money flows from the government to the local Clinical Commissioning Group (CCG), a group of administrators and General Practitioners (GPs) who oversee expenditure. The CCGs asks local hospitals, referred to as a ‘Trust’, to provide secondary care for a certain cost. If an individual trust cannot provide the service, the service may be provided by 2 or more Trusts. This is relevant to more specialized services, which may only be offered in a bigger, city-based center, referred to as tertiary care.
Levels of Care
There are several levels of care within the NHS.
Primary Care: This is provided by a General Practitioner (GP),colloquially called Doctor. A GP will care for a patient from birth until death and is trained broadly in all fields of medicine. They provide primary care to children and adults. This is similar to outpatient family medicine. Notably a pediatrician in the UK is considered secondary care and they do not take part in preventive care.
Secondary Care: This is specialist care provided in a hospital setting (both inpatient and outpatient). A referral from the GP is required. Specialties include: all medical specialties, Accident & Emergency, Pediatrics, Surgery, Psychiatry, OB/GYN etc.
Tertiary Care: Specialist and Sub-Specialist care for complex health conditions which requires a referral from a GP (and normally also from secondary care).
Outpatient Care: This is similar to US managed care systems like Kaiser. The patient will first see their GP. If the GP needs a non-urgent specialist opinion, the patient will be referred to secondary care in a hospital-based clinic (aka secondary care clinic). The referral is triaged by a secondary care consultant. If the patient does not meet the threshold for secondary care, the specialist consultant will advise the GP as to the next steps in care and the patient’s care will remain under the GP. If the referral is accepted and the patient requires secondary care, the specialist consultant will assume the work up and care. When the patient is stable or cured, patient care will return to the general practitioner or outpatient community-based specialist.
Inpatient Care: The patient will present to Accident & Emergency Department (A&E) either on their own or through a GP referral. After a workup, the patient will either be appropriate for the outpatient setting (‘discharged to GP/specialist clinic’) or they will be admitted under the most appropriate specialist service. Surgical patients will be admitted to the appropriate surgical team. Medical patients will normally be admitted to Acute Medicine.
Acute Medicine: This is the medical specialty most similar to Internal Medicine hospitalist. This specialty will investigate, diagnose, and treat medical patients in the first 48-72 hours of their hospital stay. Patients who can be discharged within this timeframe may not need to see another specialist. Patients who require ongoing inpatient specialist care will be transferred to the appropriate team. Once stabilized, the patient will be discharged to the outpatient setting (either GP or secondary care clinic).
For example, a patient admitted and found to have a Pulmonary Embolus will be cared for by Acute Medicine for the first 2-3 days and then transferred to a pulmonology ward. After stabilization, they will be discharged to the care of their GP or a secondary care clinic, depending on their needs.
In general, once a patient is admitted to a ‘parent’ team, it is the parent consultant’s responsibility to look after them for the duration of their hospital stay. Consults from other specialties do occur but it is expected that the parent consultant will have ownership for all of the patient’s health issues. For example, if a patient is admitted to Gastroenterology for viral gastroenteritis, and also has pneumonia, NSTEMI, and AKI on CKD, the GI consultant will care for all these issues. It is unusual to have several consultants tackling each organ specific issue for a single patient.
The work-life balance is better in the UK than in the US. Most consultants work Monday to Friday, with some call, and very little night work – if at all. Night call is more common in surgical specialties.
Working in the NHS requires frequent self-assessments and assimilation of feedback. There is an annual appraisal performed by the Locums Agency or the Trust. An assessor will review your portfolio of clinical self-assessment, CME, projects, presentations at meetings, and educational endeavors. An acceptable appraisal allows you to continue to work. There is also a requirement to renew your medical license every 5 years.
Transitioning from the US system to the NHS requires patience, the systems are very different and learning your way around the NHS takes time. There are many frustrations with the NHS, including time delay in obtaining investigations and treatment. Patients will only receive specialized care and work up only when it is clinically indicated. Elective procedures are done on a first come first served basis, and only those with a compelling clinical need jump the queue. It is normal for inpatients to wait several days for imaging or procedures or for outpatients to wait several weeks to months depending on their need. The only exception to this is cancer care where patients are placed on a time specific pathway and national targets must be met.
The NHS has a standard salary for the entire country ranging from £76,000- £107,000. The years of service in the NHS as a consultant determine the salary. Time worked in the NHS as a locum in normally taken into account – if you have worked 5 years as a locum, you would enter on the year 6 pay scale. Jobs in London or just outside will often offer a small ‘London weighting’ stipend. This is a small percentage of the annual salary which compensates for the increased cost of living in the London area.
It is possible to negotiate your salary if you have considerable experience at a consultant level. This needs to be discussed with the Trust for which you are considering a job. Some physicians supplement their NHS salary with a private practice. The private practice must be done on a physician’s own time separate from their commitment to the NHS. A physician may choose to work for the NHS Monday through Thursday and for their private clinic on Friday. Alternatively, some physicians have evening private practice hours after their NHS time. Conducting private practice hours while on NHS time is strictly prohibited and can cause you to be referred to the General Medical Council, this is the equivalent of going to professional court and potentially losing your license.
Consultant jobs are standard and are determined by a ‘job plan’– a personalized detailed agreement about your work. This involves a plan of Programmed Activities (‘PAs’) where 1 PA= half day session. A typical consultant job plan ranges from 10-12 PAs. Compensation is standard for time worked on weekdays and Saturdays between the ‘sociable hours’ of 0700 and 1900. The other ‘unsociable’ hours are paid more. On-call time is paid with a small annual stipend, normally a negotiated percentage of your annual salary based on the frequency of call. Locum shifts are readily available, paid hourly, and vary in pay depending on whether you use a locum agency or are paid directly by the hospital. Once you have obtained your medical license, register with a few locum agencies as they will work hard to find available locum shifts. This is an easy way to get NHS experience and be paid well. More on this in Part Three.
There are some small private hospitals that provide low risk surgeries for low risk patients. These hospitals typically do not have ICUs nor doctors overnight. A physician may have a higher salary in this type of job.
Job opportunities are need based and are dictated by the government. The government considers the supply and demand for each specialty; hence there are a limited number of available positions. This is true right from the training pathways—the government decides how many trainees are needed for each specialty and only allots that amount annually. There is a fixed number of jobs to choose from, and if the need isn’t there, the job isn’t created. Trusts may decide to create jobs if there is a need/gap. This is done on a case by case basis.
Connecting with locum agencies and searching NHS jobs is the best way to apply for jobs. Popular areas and institutions often do not have vacancies and it is common for a consultant to wait for someone in a department to retire before there is a vacancy.
As an international medical graduate, there is no required period of supervision, though it is advised to work with a mentor or to work one level down for several months to get the lay of the land. It is often best to work with a locum agency or a local Trust where you want to work in order to determine how you can best be employed.
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Pulse Psychiatry is a leading UK psychiatry staffing agency matching your expertise and experience with your ideal role. Their recruitment team will work tirelessly to bring you exciting opportunities in the NHS and private sector, many of which are exclusive to Pulse. Whether you’re looking for a permanent or temporary role, their support will help you to exceed your career goals. Pulse Psychiatry offers relocation support, access to 1000’s of jobs, flexible opportunities, and a rewarding referral scheme. Pulse is proud to have been awarded Approved Supplier status by Procurement in Partnership and HealthTrust Europe (HTE). This award recognizes their commitment and expertise in supplying highly qualified locum and permanent doctors.
Head Medical is a leading specialist in international medical recruitment, having helped 1,000s of physicians find new roles in amazing locations including UK, Australia, New Zealand, Singapore, China, the Gulf, Canada and Caribbean. So, if you think you might be interested in a new challenge and a change of scene, please get in touch for a chat with one of their recruitment specialists. Their expert team will support you with your licensing and immigration paperwork and provide practical advice to ensure your relocation goes as smoothly as possible.
Dr Yunger is originally from the US and completed her Internal Medicine training and board certification in 2012. She now lives and works in the UK.
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