Re: Over Half of Graduating Family Medicine Residents Report More Than $150,000 in Educational Debt

To the Editor: We read with interest “Over Half of Graduating Family Medicine Residents Report More Than $150,000 in Educational Debt,”¹ which provides an insight into the debt that the average American medical student accrues and subsequent effects on primary care recruitment. The authors proposed that this is due to financial repercussions of choosing this specialty. We would like to give an account of a similar recruitment crisis here in the United Kingdom (UK).

In the UK we have always been aware of the large amounts of debt that medical students in America accumulate. However, we always felt that we were exempt from such concerns here thanks to the existence of a state-funded education system with the aim of free tuition for all. However, during the last decade tuition fees have increased from £1,000 to £9,000 ($11,770) per year. This means that UK students are graduating with more debt than ever before, which is especially pertinent for lengthier degrees such as medicine.

A recent study² found that medical students would graduate in 2014 with a debt between £64,000 ($83,700)* and £82,000 ($107,241) dependent on the amount of maintenance loan required for housing costs and food. This is comparable to figures quoted by Bazemore et al,¹ although admittedly the highest UK debt is less than half of the highest American debt. However, it is worthwhile bearing in mind that UK general practitioners (GPs) can expect to earn approximately $43,000 less per annum than their American counterparts³. This study² also calculated that doctors on an average UK salary would be unable to repay this loan before debt is written off after the 30th year following graduation.

This level of debt adds an unfamiliar pressure to UK doctors planning their career. This is a particularly sore topic given that previous generations of doctors enjoyed free education, with many receiving grants to attend university. However, does this level of debt dissuade graduates from choosing primary care? We believe that factors other than financial concerns are at play.

Despite government promises of 5000 new GPs by 2020 and 50% of medical students graduating in 2016 earmarked to go into primary care, recruitment in primary care has not increased. The number of GPs as a proportion of National Health Service doctors has instead decreased nearly every year in the last 20.⁴ Is this due to a financial disincentive?

In 2016 the average GP earns up to £84,453 ($110,449), compared with up to £102,465 ($134,000) earned by a consultant in a secondary care institution.⁵ However, GPs will reach their peak earnings much earlier due to fewer years of training required. Furthermore, GPs that own their practice can expect to match or surpass the earnings of a consultant. Thus, it seems there is financial incentive to choose UK primary care; however, the recruitment crisis persists.

Clearly other factors are at play. Growing discontent among GPs in recent years has lead to dwindling retention, with 30% of GPs now intending to leave direct patient care in the next 5 years.⁴ Furthermore, primary care is not viewed by young doctors as the appealing career it once was, with many using it as a back-up choice.

The primary care recruitment crisis here in the UK shows no sign of imminent improvement. This is despite an unprecedented level of student debt and certainly some financial incentive to enter UK primary care. We propose that aspects of modern family practice other than financial implications may be guiding doctors' career decisions. Perhaps for the picture of primary care recruitment to change more than a simple financial incentive is needed.