'27 doctors for each job': why are there so few training posts for specialties facing staff shortages?

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By Emma Wilkinson

Frustration and stress mounts as doctors struggle to secure specialty training places despite widespread shortages of senior specialists, leading many to worry if they’ll have a job at all.

For our next generation of doctors, the future looks increasingly uncertain. Competition for specialty training places is increasing year on year and new medics are up against applications from those with one, two or more years’ extra experience. They have debts to pay and trusts facing financial black holes are being told to cut back on rising locum bills.

Yet the NHS is short about 50,000 full-time equivalent doctors compared with the OECD EU average, rotas are unfilled and tensions are high.¹

Dr Shonnelly Novintan, a core surgical trainee in Essex, has many friends who cannot even get an interview for the first stage of speciality training and cannot find other jobs either. “It’s very demoralising,” she says.

As someone who wants to do plastic surgery, in a year or two she will be applying for one of 50 jobs against typically 220 applicants. “Once I’ve got through my core surgical training, I will have 14 to 15 months to put together a portfolio to meet this very high standard,” she explains. “That is really difficult so people take some time out, which you can be penalised for. It’s all very Catch-22.”

For some, the prospect of a year off might be appealing but for others it’s “a forced reality”, she notes. “We have these new medical schools emerging all the time but no definitive plan on how to increase the training numbers. There’s just no jobs for them.”

Specialty demand data ‘lacking’

Last year’s long overdue NHS workforce plan agreed that the UK is under-doctored compared with many other comparable counties. The country is also struggling with retention, uses too many temporary staff and is reliant on overseas recruitment.

We need a better pipeline, it concluded, calling for a doubling of medical school places by 2031. GP specialty training places will need to grow by 45-60% over the next decade, it said. A commensurate expansion will need to happen in training for other specialties but the detail would come later, it added.

Dr Sarah Clarke, president of the Royal College of Physicians (RCP), says the supply of doctors right now across many areas of care is simply not enough. Yet the workforce plan did not have “the robust data needed on medical speciality demand” to make an informed projection about training places.

She says: “Fundamentally we need to know how many specialty training places are needed and where. The National Audit Office’s recent report recommends that NHSE [NHS England] makes more of the opportunity to consult external stakeholders to produce all its future modelling.” The RCP has and will continue to offer its help to plan for this, she adds.

The workforce plan also pledged to complete by September a planned rise in specialty training places of more than 2,000 over three years, plus an extra 1,000 places in areas with shortages.

Yet, a common message from all royal medical colleges is that while there has been expansion of training posts in recent years, it is not enough.

The Royal College of Anaesthetists has calculated a shortage of 1,400 anaesthetists and wants to see at least 100 additional higher speciality training places a year. The Royal College of Emergency Medicine has also sounded the alarm (pdf) over a mass exodus of senior doctors, leading to a reliance on locums and consultants seeing twice the number of patients they should be. It wants a minimum expansion of 120 emergency medicine training places for 6 years, starting this year.

Professor Jeanette Dickson, chair of the Academy of Medical Royal Colleges, says the complexity of workforce planning is often underestimated. Changes in medical practice, patient demographics, ensuring equitable access in underserved areas of the country and increasing numbers of doctors working less than full time all need to be factored in.

In cardiothoracic surgery, 298 doctors vied for just 11 jobs.

Competition ratios tell you how many people apply for a certain job but it is hard to know how “real” they are because doctors can apply for multiple specialties, she explains. In 2023, five doctors applied for every post in emergency medicine, anaesthetics, and psychiatry. Double that for radiology and public health. In cardiothoracic surgery, 298 doctors vied for just 11 jobs around the country.

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F3+ competition

The path that doctors take after those first two foundation years has also changed - it is the ‘new normal’ to take a break. A report commissioned by the General Medical Council found 50% of doctors now take an ‘F3’ year. A survey of 4,000 doctors highlighted various reasons including not wanting to be tied to a specialty. For most, this was an active choice.

“We have seen more doctors taking time out,” says Professor Dickson. “It means we have not just got those coming out of F2 but we have F3, F4, F5 and those changing specialty applying for the same jobs.”

Yet some training posts remain unfilled despite the high levels of competition because they are in places people do not want to move to.

That is not to take anything away from the stress and uncertainty that many trainee doctors are reporting, Professor Dickson insists. They are in the unenviable position of entering the system at the point at which everyone is getting to grips with how training expansion will work. “The juniors coming into this now are upset and panicked and they want to progress their careers and I have great sympathy with that,” she says.

‘Trusts say they can’t afford it’

The next iteration of the workforce plan is due early next year. But it will have to fit within a certain financial envelope, with cash-strapped trusts and GP practices finding money to top up the half that is centrally funded.

Another piece of a complicated puzzle is that agreed expansion has not always translated into posts on the ground, says Dr Katharine Halliday, president of the Royal College of Radiologists. The specialty has seen protected growth in training numbers - albeit not to the level that is needed - but is finding it hard to place the extra trainees because “trusts are saying they can’t afford it”.

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Other barriers include overworked radiologists unable to take on extra supervision. “It does have to be done gradually,” says Dr Halliday. “You can’t suddenly double the number of places because we have training capacity at the moment which we’re not filling.”

The average retirement age in radiology has now dropped to around 51, explains Dr Halliday. “We need to think very carefully about what we want our senior workforce to be doing and need to be quite imaginative about the way we keep them in the workforce, including keeping people on to mainly teach.”

‘We desperately need more GPs’

In the first round of this year’s application for GP training, a record 15,036 doctors applied for 4,000 ST1 posts. It raises questions about whether expansion is happening at the speed needed.

Yet there are very practical barriers. Royal College of General Practitioners (RCGP) chair Professor Kamila Hawthorne says it is encouraging to have more GP trainees than ever before but a burnt-out workforce also means we are losing GPs with years of expertise and experience “faster than we are gaining them”.

She says: “Put simply, we desperately need more GPs - the average number of patients per fully qualified GP continues to rise and is now a staggering 2,294.” She calls on the government to pull out all the stops to increase the number of new GP trainees by 2,000 a year by 2031 as promised.

The state of general practice infrastructure is a real problem. The Shakespeare Health Centre in West London told Doctors.net.uk it has had to cancel its training scheme because its premises were not fit for training purposes. A 2023 RCGP report found 66% of GP practice staff said limited space made it difficult to train new GPs and 75% found that it restricted the number of trainee GPs they could have.

“The NHS is so short-staffed and that is not reflected in the number of training posts,” says Dr Pushpo Hossain, international medical graduate (IMG) lead at Doctor’s Association UK. “If you saw the rotas you would see it is understaffed.”

It cannot be discounted that part of the great dissatisfaction among trainee doctors at the moment is that they can also see rotas being filled up with physician associates, who have salaries equivalent to an ST3 level, she adds.

“We definitely need more doctors in training, we need more doctors to staff the wards, we need more GPs and the doctors who are there are exhausted,” Dr Hossain explains. “It’s maddening.”

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A lack of consultant jobs

For IMGs, the situation is very hard because, despite being eligible, they have less chance of getting an interview for the limited number of training places due to a lack of NHS experience, and yet are also struggling to secure roles to give them that experience to boost their chances in the future. “They don’t have any way to get a job,” says Dr Hossain.

The bottlenecks are having an impact at all levels, she notes. She met a trainee who had a post on one of the most competitive specialities - neurosurgery - but was giving it up to move into psychiatry because there were no consultant jobs at the end of it. “He was so passionate and had already done core surgical training.”

Dr Helgi Johansson, vice president of the Royal College of Anaesthetists, says they are crying out for doctors but approval for more training places has been slow. “But there are lots of things we can do around increased flexibility of training and streamlining processes to help get people through speciality training quicker,” he says.

“There is also the portfolio pathway [for speciality doctors] which more and more UK-trained doctors are doing, some of which has come about because of those competition ratios. I am confident that pathway can help us out quite a lot in the next couple of years.”

Dr Rob Fleming, a specialty and associate specialist (SAS) anaesthetist, is a founding member of the SAS Collective, a lobbying group trying to standardise the approach to careers outside of formal training. He was one of the first of the new foundation doctors entering into the profession after the Modernising Medical Careers overhaul. For various reasons, he decided to step off the ladder at ST4 and found that trying to progress his career “was a lot more difficult than it ought to be”.

The NHS workforce plan acknowledged that more doctors were choosing alternative career paths but trusts do not consistently offer substantive specialty doctor jobs, says Dr Fleming.

“Organisations need to be shown why it matters enough to do it, because no one's policing it and no one's funding it,” he says. Figures show potentially 30% of the medical workforce are currently outside specialty training, which is also the most ethnically diverse part of the workforce, and they often don’t have the best job opportunities, he adds.

There is a lack of joined-up thinking, he says, with NHS England pushing trusts to use fewer locums on the one hand, but without other roles available. “There are people coming out of UK medical schools now looking almost as soon as they graduate for how they get out of the country,” says Dr Fleming.

“They're not planning the next step as specialty training in the UK.”

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References

1. British Medical Association. NHS medical staffing data analysis, 26 April 2024

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