The Junior/Resident Medical Workforce in the NHS: Challenges, Opportunities, and the Road Ahead
Umesh Salanke
Medical Director - Medical Academy at University Hospitals Birmingham NHS Trust
The National Health Service NHS in the United Kingdom is widely regarded as a cornerstone of healthcare excellence. However, it currently faces significant challenges, particularly concerning its junior/resident medical workforce. Recent data and trends reveal a landscape that is both promising and fraught with issues demanding urgent attention. This post explores the key challenges and opportunities, informed by data from the General Medical Council (GMC) General Medical Council , the NHS Long-Term Workforce Plan, and other relevant sources. There seemed be a genuine effort to cover all aspects of medical Workforce under one common umbrella of NHS- Workforce, Training and Education Directorate (NHS-WTED).
The key element is to have a collaborative approach from across various organisations
The Composition of the Junior Medical Workforce
The junior medical workforce in the NHS is diverse and dynamic. According to the GMC’s "The State of Medical Education and Practice in the UK: 2023" report, there were approximately 356,000 doctors on the medical register as of 2023, an increase of 13% since 2017. Notably, the number of UK-trained doctors has grown more modestly by about 9%, while the number of International Medical Graduates (IMGs) has surged by 33% over the same period. As of 2023, IMGs account for 39% of doctors who joined the UK medical workforce, reflecting the increasing reliance on overseas doctors to meet staffing needs. This is a significant jump from previous years, highlighting both the opportunities and challenges of integrating a global workforce into the NHS. Meanwhile, Locally Employed Doctors (LEDs)—doctors not in any formal training posts—comprise a growing segment of the workforce, making up about 15% of the medical workforce. These doctors often fill service posts rather than training posts, and many face limited career progression opportunities, leading to dissatisfaction and high turnover rates.
Supporting our Local Graduates: The Need for Targeted Interventions
Supporting UK-trained graduates is crucial to the NHS's long-term sustainability. Despite the increasing number of medical graduates from UK universities, many face challenges in securing specialty training positions. The transition from foundation training to specialty training is often fraught with uncertainty, leading to a growing number of doctors opting for a "Foundation Year 3" (FY3) year. The FY3 year, where doctors take a break after completing their two-year Foundation Programme, has become increasingly popular. During this year, doctors typically engage in locum work, travel, or gain additional experience in different specialties before committing to a specialty training pathway. While this flexibility can benefit doctors, it also reflects underlying issues in the system—namely, the intense competition for specialty training positions and the desire for better work-life balance. To better support local graduates, the NHS must address the reasons behind the growing FY3 phenomenon. This includes expanding specialty training positions
Additionally, trusts can implement targeted support programs to help foundation doctors transition smoothly into specialty training or other career paths within the NHS. This would need a coordinated approach between Medical Education, Human resources and Operational Teams in the NHS Trusts. Remember, our local graduates know our Patients, the NHS Culture and the Social service systems very well.
NHS Long-Term Workforce Plan: A Step in the Right Direction?
The NHS Long-Term Workforce Plan, launched in 2023, aims to address some of these challenges by expanding the number of UK-trained doctors and enhancing the training pipeline. The plan proposes to increase medical school places by 50% by 2031, adding approximately 5,000 more students annually. This is a positive step, but merely increasing numbers is insufficient. Equitable distribution of training opportunities is crucial. The workforce plan also emphasizes retaining experienced staff, particularly in light of significant vacancy rates, which currently stand at over 112,000 across the NHS, including nearly 9,000 medical vacancies. There seems to be genuine effort from various national organisation to address this gap, the key would be have a collaborative approach involving relevant parties.
Specialty Training and Applications: A Growing Bottleneck
Specialty training remains a critical bottleneck in the development of the NHS workforce. Despite an increase in medical school graduates, the number of available specialty training positions has not kept pace. For instance, the competition ratio for popular specialties such as dermatology and cardiology can exceed 4:1, leaving many junior doctors in a competitive race that can impact morale and career satisfaction. Conversely, there are plenty of services heavily relying on Locum doctors for day to day activities ( e.g. A&E, O&G etc) , leading to shortages in areas critical to running a safe and effective NHS service. This imbalance not only frustrates the career aspirations of junior doctors but also threatens service delivery and patient care.
The Role of International Medical Graduates
International Medical Graduates are increasingly becoming the backbone of the NHS, particularly in underserved areas. According to the GMC, IMGs made up 63% of all doctors joining the NHS in 2022. Their contribution is invaluable, yet their journey often involves navigating a complex system, from obtaining necessary qualifications to securing training opportunities. Better integration of IMGs into the NHS is essential, including more structured support and mentorship programs. Some trusts have implemented exemplary induction programs, which could be scaled up nationwide to enhance the IMG experience and retention.
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Specialist SAS & LE Doctors and the CESR Pathway
Specialty and Associate Specialist (SAS) doctors are integral to the NHS, often bridging the gap between junior doctors and consultants. As of 2023, there are around 43,000 SAS doctors, many of whom are highly experienced and deliver crucial services. Despite their vital contributions, SAS doctors have historically been under-recognized. The Certificate of Eligibility for Specialist Registration (CESR) or portfolio route has become an increasingly important pathway for SAS and LE doctors. This pathway allows doctors who are not in traditional training programs to achieve specialist status by demonstrating equivalent competencies through their experience and portfolio. The CESR pathway is essential for enabling experienced SAS doctors, including many IMGs, to attain consultant-level positions. However, the process can be demanding and time-consuming. NHS trusts must provide robust support and clear guidance to help SAS doctors navigate this route successfully. By doing so, the NHS can reduce its reliance on locum doctors and strengthen its consultant workforce. The recent steps towards supporting Specialist SAS role is a welcome move. The NHS Locally Employed Doctors Blueprint for Change and SAS Excellence in Development Recognition Award is very encouraging.
Safe Staffing and the Role of Locums
Safe staffing levels are crucial for patient safety and staff wellbeing. The Royal Colleges have established guidelines for safe staffing, but many NHS trusts struggle to meet these standards. The use of locums to fill gaps has become widespread, leading to significant financial costs. NHS England's 2023 report indicated that the NHS spent approximately ￡3.3 billion on agency and locum staff in 2022, a significant burden on an already strained system. While locums are essential for maintaining service delivery, this is not a sustainable long-term solution. The focus must shift to developing our own specialists in-house. This includes expanding specialty training posts, supporting SAS doctors through the CESR pathway, and creating more consultant posts. Investing in training and development will reduce the reliance on locums and improve continuity of care, ultimately leading to better patient outcomes.
Developing Our Own Specialists: The Way Forward
The NHS must prioritise the development of its own specialists. Expanding specialty training posts, providing more opportunities for Doctors in Training (DiT), LEDs, IMGs, and SAS doctors to transition into training roles, and ensuring all doctors have a clear and achievable career path are essential steps. Trusts that have developed innovative training programs for LEDs and SAS doctors offer valuable models that should be scaled up across the NHS. These initiatives not only improve career progression opportunities but also enhance job satisfaction and retention.
Conclusion: A Call to Action
The junior/resident medical workforce is the lifeblood of the NHS. To ensure the long-term sustainability of our health service, we must address the challenges facing this group head-on. This requires a coordinated approach involving investment in training, better support for Doctors in Training, LEDs, IMGs, and SAS doctors, and a commitment to developing our own specialists. The NHS Long-Term Workforce Plan is a step in the right direction, but its success will depend on effective implementation. By working together, we can create an NHS that not only attracts but also retains the best talent, ensuring a safe and effective service for all.