Episode 7 Inside Out

Now on BBC News it's time for Inside Out.

Hi, I'm Elaine Dunkley, and welcome to Inside Out.

This week we've got a series of special reports from the front

line of the NHS across England coming up: there's a shortage

of medics in the UK, but as we lure in doctors

from overseas, what's the impact on those left behind?

We meet the 82-year-old Romanian brain surgeon.

And with a shortage of GPs as well, how can we persuade more trainee

doctors to go into general practice?

If you could take a breath in and out for me.

We reveal how stressed junior doctors are facing a growing

mental health crisis.

A survey by the BBC suggests more than two-thirds of hospital trusts

across England are trying to fix a serious shortage of medical staff

by looking abroad.

But by luring doctors here, is the NHS simply causing a crisis

elsewhere, and should we care?

Chris Jackson has been to one Eastern European country to ask,

are we getting their doctors on the cheap without any regard

to the consequences?

Two doctors, one young, one old, both Romanian.

Luisa Baca is inserting an abdominal drain.

She works in Romford.

I love my job.

I love working with patients.

Did your tummy get bigger, basically?

The NHS is a world-class health system.

I get here the opportunity to learn something new and not worry

about your rent.

Leon Danailla practices brain surgery back in Romania.

TRANSLATION: I don't have a large fortune.

I think I'm the poorest doctor in the world.

Two systems, one rich, one poor.

The rich, the NHS, sucks in talent from around the world,

at the expense of the poor.

So what is that doing to Romania?

Bucharest.

Leon is removing a brain tumour.

He'll be 83 in July.

TRANSLATION: If the doctor is in good health, it's good to work

into old age.

I don't use glasses.

My hands don't tremble.

Leon earns less than ?500 a month.

He is one of thousands who couldn't retire even if they wanted to.

They are desperately needed.

There are so few young doctors here.

It means medicine in Romania is increasingly becoming

a pensioner's profession.

Last year there were more than 8,500 doctors over the age of 60.

Compare that with 1,300 under the age of 30.

Across Bucharest, students from the Carol Davila medical school.

In Britain it costs just under ?200,000 to train a medic.

But it costs next to nothing to take one ready trained from here.

There's just the wages to pay.

So in effect Romania is subsidising our health service.

We seem to like it that way.

So do the students here in Romania.

The United Kingdom is on top of my list.

My first and technically only choice is the UK.

They will join around 2,000 Romanians practising in Britain.

They can earn ten times what they get here.

The higher wage is really the main reason I would go abroad.

And there's another way that Romania subsidises the NHS.

Believe it or not there are British students training here in Bucharest.

Britain limits its medical school places, it even cut them three years

ago because the government thought there'd be too many hospital

doctors in future.

So British students rejected by our medical schools come

to countries like Romania instead.

Guess what?

Once they are qualified we snap them up, despite saying no

a few years earlier.

Like Arran Williamson who has been studying in Romania for two years.

And Anil Velivela, who's been here for three.

I didn't get a place in a UK university and I read

about the opportunities to study abroad.

Classes themselves are in English.

I'll be fully qualified to do the job.

It's a little loophole and I was very surprised

when I read about it.

But it benefits me so I'm happy about it.

Like the Romanians, their training also costs the NHS nothing.

Back with our doctors Leon and Luisa.

A success, you hope?

I want tomorrow to see.

Both are concerned about the exodus of medics to countries like Britain.

TRANSLATION: Yes, they are a loss to the Romanian health system.

We need a lot of doctors.

We are not encouraging enough junior doctors to stay,

and it's not only about the pay, it's about investing

in the hospitals.

Proper services to support the patients.

Our hospitals scour the world with shopping lists of doctors.

Mark's made his business to supply them with talent.

It's a very busy business.

Hundreds of thousands of agencies are competing for these doctors.

The most sought-after specialties are acute medicine,

accident and emergency, intensive care, paediatrics,

psychiatry and radiology.

Across Bucharest, 87-year-old cardiologist Leonida Gherasim.

It's claimed here that poaching the young is making

health care dangerous.

TRANSLATION: This is my concern.

You not only lose individuals, you lose their capacity

to train others.

It's a disaster.

In great towns maybe there are enough doctors.

But in important towns with more than 100,000 inhabitants,

the medicine in these places is done with danger.

That's because specialists have to work in areas

they know little about.

For example, cardiologists could be required to help out

in intensive care.

Back with Luisa in Romford.

Her day is coming to an end.

Her time in Britain isn't.

Short and medium-term I want to train and to specialise

here in the UK.

I will give a phone call to your wife to tell her

about the medicines as well.

It's a privilege to help my patients, and to be trained

at my best, it's both a duty and a pleasure, yes.

In Bucharest Leon's patient has regained consciousness.

TRANSLATION: Does anything hurt?

My head.

Your head?

Well, what can we do?

That's where the problem is.

I don't know when I'll stop.

Yes, certain illnesses or situations could make me step aside.

Surgery isn't a joke.

People's lives depend on it.

With the present trend many of the doctors we'll need over

the next decade will no doubt come from places like Romania.

The question is, should Britain expand its medical schools or is it

just cheaper and easier to rely on poorer countries like Romania

to fill the gap and pay the price?

Doctors have always supported free movement of labour.

The British Medical Association is concerned about the effect

of excessive foreign recruitment.

There's always a balance, here.

Overseas doctors have always been the backbone of the National Health

Service.

But I do get worried when I hear about the way we can go abroad

and deliberately recruit too many people, to the extent

that there are some countries where a substantial proportion

of their doctors are coming to work in the United Kingdom.

And that could be worrying for those countries.

Because we are not doing them a service.

Early last December we asked the Health Secretary Jeremy Hunt

for an interview to discuss the issues raised here.

A month and a half later he declined.

So we asked the health minister Ben Gummer.

And last week, almost a month later, he declined.

We wanted to ask them on your behalf why we can't train enough

of our own doctors.

Would the system collapse without the foreign staff?

And isn't it wrong to exploit the health systems

of poorer countries?

The Department of Health did issue a statement.

It said staffing was a priority, and there are now more than 10,700

additional doctors since 2010.

And more than 55,000 doctors in training.

Overseas staff are crucial to the NHS, but we must also train

the right number of staff here.

Experts were reviewing the number of medical degree places.

It's pretty clear that in places like Romania,

that review is going to be watched very closely.

Have you found it difficult to get a GP appointment?

Well, statistics show there simply aren't enough doctors to go around.

In fact the Royal College of GPs claims that in parts of the country

at least 50% more doctors will be needed by 2020.

So why the shortage?

Well, some GPs are simply leaving the profession and it's becoming

increasingly difficult to recruit new ones.

Mary Rose has the story.

Doctor Andrew Green runs a GP practice in Biddulph in

Staffordshire.

When he needed to recruit a new GP, he was shocked by the response.

We advertised in the British Medical Journal, advert ran for two weeks,

and nobody applied.

Nobody applied.

It's hard.

It gets very hard.

The British Medical Association claims part of the problem is that

many GPs are retiring early or moving abroad

because they are unhappy with workload pressures.

But in this part of the country the lack of trainees is also

a major factor.

Nationally one in five vacancies for trainee GPs go unfilled.

But in the West Midlands it's one in three, and it's having

a big impact.

Lovely, that's it, just short and sharp.

Here in Biddulph they are having to use senior nurses instead

of doctors to treat some patients.

So why are so few trainee doctors choosing to become GPs?

Well, let's ask one.

In just five months trainee Sasha must choose which profession

to go into.

That's good, blood pressure stable.

Like all trainees she does work placements which allow her

to sample different roles.

They last two to three months and at least one must be

with a GP practice.

But like many trainees she doesn't find general

practice that appealing.

Some people might think it's a little less exciting than hospital

medicine, not as busy, a bit more like office type work.

Currently I see myself becoming an acute medical physician

but there is always room to change my mind.

Which leads us to a crucial question.

Would more trainees be won over by general practice if they spent

more time seeing GPs in action?

Let's find out.

Today Doctor Andrew Green is going to try to persuade trainee

Sasha to become a GP.

I'd like to think that I can make her think about it

as a positive career move.

It will be nice to see what his practice is like and what he can say

to persuade me, really.

Nice to meet you.

As you can see down here, quite a large practice.

Clear day like today you can see right up to Manchester.

This is what you could have being a GP in Biddulph.

It is a very nice view.

Andrew suspects Sasha finds the idea of working

in a hospital more exciting.

But he has his own take on life as a hospital doctor.

What could be worse than doing an afternoon clinic where you know

everybody has already got glaucoma?

Everybody has got the same condition.

Doing the back pain clinic or the varicose vein clinic.

According to Andrew general practice is far more interesting.

One of the great joys and excitements is you do not know

what is going to walk through the door next.

You have no idea why Mary Smith has booked that appointment at 10:30am,

it could be anything.

Absolutely anything.

So it's a lot of variety.

Of course it's variety.

Next Andrew takes us for a stroll in the community he serves.

He seems to know everybody in town and for him it's another

unique selling point.

You build close relationships with people, and you don't get that

in other branches of medicine.

Are you really at the forefront of medicine?

Are you really where it sat at the cutting edge?

More and more.

Things that were treated in hospital five, ten,

20 years ago, we now deal with those.

Diabetes, heart failure.

Severe asthma.

Finally we join Andrew on his rounds.

He is visiting patient Leonora to examine a wound on her leg.

Over the years he's treated four generations of her family.

Is that sore at all?

After a new prescription Leonora gets chatting to Sasha.

I need to decide whether to become a GP or a hospital doctor.

You should be a GP.

Why do you say that?

Well, we need GPs, don't we?

So, after the charm offensive, the verdict.

Having done one house-call and spent some time with Andrew

and seen his practice, any closer to persuading you to go

down the GP route?

A little bit closer I think but not quite there yet.

Just seeing how you interacted with her, how she trusted you,

and the rapport you had with her, and the long line of family that

you've been seeing and visiting, it made me want that as well.

I am a little bit closer but not quite there yet,

I think.

All the best.

So Sasha still isn't persuaded, but it's vital other trainees

are won over, otherwise we will all struggle to get

an appointment with a GP.

Over the past few months, junior doctors and the government

have been at loggerheads over changes to new working contracts,

many have been out on strike twice already this year.

The dispute has shone a spotlight on their often challenging working

conditions, and Inside Out in London has now uncovered evidence

of a growing mental health crisis among junior doctors.

Record numbers are now being signed off with depression and burn-out.

Senior health officials are warning that the system is close

to breaking point.

Emilia Papadopoulos has the story.

And if you could take a breath in and out for me.

Junior doctors have been called the workhorses of the NHS,

and are responsible for much of the diagnosing, patching

and mending that takes place in our hospitals.

Registrar here, I just wanted to check when my patient

was going to have a CT head.

31-year-old junior doctor Salwa Malik is completing her

training in emergency medicine at a London hospital.

Basically you've got to see first of all who is the next patient to be

seen, but also the order of priority.

Are you able to sit forward for me?

It hasn't stopped, it's got busier and busier.

I haven't had a cup of water yet today so I'm quite thirsty.

You seem a bit wheezy and you've been coughing up some green phlegm.

I feel exhausted.

It's very easy to make mistakes.

You have to be on the ball all the time.

Gone is the day when you can say Monday and Friday are the busy days.

I think Thursdays are particularly bad.

Tuesdays are particularly bad.

Actually Wednesdays are pretty bad as well.

For Salwa and the 50,000 other junior doctors in England it's often

a constant battle to keep their heads above water and deal

with the demands of the job.

For some, the pressures can be overwhelming.

I trained at Imperial College in London and qualified

as a doctor in 2010.

I was on a cardiology rotation.

And for about two months, staying on until about 8pm,

8:30pm most nights when I was meant to finish at 5pm.

And what I found out was I was actually doing the job

of two doctors.

And the other post was even not advertised or just left unfilled.

Reena started to struggle with the extra workload

she was having to take on.

I was honestly just exhausted.

But more so than that, my mental health suffered.

I started becoming quite anxious.

Worried constantly.

And feeling dread to go into work the following morning.

Reena's bad experiences with work rotas seem to be increasingly common

in the NHS.

According to a study by the British Medical Association,

the numbers of junior doctors reporting long-term rota gaps jumped

from 46% in 2014 to 60% last year.

We are seeing a situation now that is not simply junior

doctors not being able to cope with the stresses of medicine,

this is about a government and a system effectively putting

untold amounts of pressure that don't need to be put on these

doctors, because the system is being mismanaged so horribly.

As an obstetric registrar responsible for delivering babies,

Doctor Malawana has plenty of experience of rota gaps himself.

I myself worked on a rota just recently where you needed 30 doctors

in order to deliver a safe service, and we were 11 doctors short.

You can't just leave when your shift is over because there's no one

to take over from you, what do you do?

The pressures of Reena's job finally caught up her during a stint in A

It was about 5am and I was having a full-blown panic attack.

Palpitations, chest tightness, difficulty breathing.

Mind all over the place.

And my family encouraged me to call in and say I'm sick.

And I got a call from one of my seniors basically telling me

that I was irresponsible and I was selfish for not coming in.

This just added to that sense of shame and guilt and failure.

Feeling that she was burning out, Reena decided to put her medical

career on hold.

Leaving the NHS a doctor down.

So what's been the cost of poor mental health on the capital's

junior doctor workforce?

Inside Out submitted a Freedom of Information request

to all of London's NHS trusts to measure the impact over the last

five years of junior doctors being signed off work.

The results are striking.

In 2011 over 1,200 days were lost through doctors in London

being signed off with stress, anxiety and depression.

Last year, though, this figure had jumped to nearly 3,200.

An increase of 159%.

But when junior doctors reach their breaking point,

where can they turn?

The Practitioner Health Programme was set up here in London in 2008

as a confidential treatment service for medical professionals who have

developed mental health problems.

The peak age we are seeing is 28 to 29, mainly suffering

from depression, anxiety, burn-out.

When we opened our doors we were seeing three

new patients a week.

We are now seeing up to 15.

We were so inundated with referrals that unfortunately we had to turn

the tap off and close the service down for about six weeks.

Doctor Gerada believes that front-line doctors need more

psychological support to help them deal with the heavy emotional

demands of their work.

There are doctors sitting in car parks at work just weeping,

unable to get out of the car.

These are human beings that started off, usually as 8-year-olds,

wanting to serve others.

We've taken their emotional resilience and we've crushed it

with the work that we are expecting them to do.

Some doctors are all too aware of the emotional turmoil

that the job can generate.

Doctor Zeshan Qureshi is a junior paediatrician.

Some of his work can be extremely harrowing.

I remember the first cardiac arrest I went

to, an 18-month-old.

We turned to the parents and we said, we need you to be

prepared that your child might die tonight.

And you know, that moment, the tears, the screams,

the pure and intense outpouring of sadness,

of grief, of fear, of loss.

Every time that happens it sticks with me.

You are having to deal with really intense emotions.

All of those directly contribute to increasing your personal risk

of mental health problems.

The end result of it is severe depression and post-traumatic stress

disorder.

In the worst-case scenarios people taking their own lives,

which has happened, and I've experienced with a few of my friends

having taken their lives already.

Following her breakdown, Reena experienced suicidal impulses

herself.

Eventually I got to the point where I was so low that I had

the paramedics round at my house.

Having been through that I decided that it was time to take out,

and try and look after myself first.

We are basically asking for peace on three levels.

I run something called Mindful Medics, not just for doctors

but all health care professionals.

It is a programme which encompasses these yogic breathing techniques,

and also mindfulness meditation.

We are trying to get the flow of energy within the body.

Really I don't want anyone to get to the point where I got to,

and feel suicidal.

Can you put up a multiple trauma call to A resus now, please.

Back in Salwa's A unit, things are as hectic as ever.

Does she feel warm to touch?

For Salwa and other junior doctors, their breaking point can sometimes

feel distressingly close.

I was supposed to finish at 8pm, I didn't finish until 1:30am,

I didn't get home until 2am.

It was only at 2am I realised my own father was waiting for me to talk

to me about the operation he was due to have that day,

and he wanted to talk to me about the anaesthetic as well.

And I just felt really bad because his daughter is a doctor,

and I felt like I couldn't look after my own father.

But I was trying to help someone else.

That's really difficult.

It's really difficult because I feel like I totally failed as a daughter.

Two weeks after we filmed with her, she collapsed while working,

suffering dehydration, low blood sugar and a racing heart

rate of 150.

In a statement NHS employers told Inside Out: If the NHS was a coal

If the NHS was a coal mine or a factory it would be closed

down now as not fit to provide

a safe working environment.

I have worked in the NHS for 35 years.

I have never seen so many demoralised individuals.

And unless we deal with this urgently, and I would say

by an urgent enquiry, I'm afraid we are not

going to have the staff to deliver the care our patients need.

That's it from us this week.

If you'd like to see more stories from your area join our Inside Out

teams on Monday evening at 7:30pm on BBC One,

or on the BBC iPlayer.

or on the BBC iPlayer.