It has become traditional to see stories over the winter months about the NHS in crisis. In a bleak new development, stories of institutional collapse in our healthcare system are emerging as a regular feature of early spring as well.
This year – in a repeat of last year – there is huge frustration among final year medical students still to be allocated jobs, with a large proportion yet to find out which hospital they will start work in. (Last year, NHS England gave one cohort just 18 days to find a home.)
The uncertain future of trainee doctors does not end there; competition ratios for internal medicine training (IMT) have been growing rapidly for the past few years, too. In 2024, applications for IMT outstripped the number of posts available by 73%. With such a high degree of competition, many are not so much worried about finding a new home as finding a new career, faced with losing out on training entirely.
All doctors must first complete medical school, a program lasting between four and six years. Upon graduating, they are required to apply for Foundation Training – a two-year programme in which they gain experience across various clinical specialties.
In 2024, every eligible doctor was guaranteed a place in the Foundation Programme. However, due to limited capacity, over 1,000 medical students were assigned ‘placeholder’ positions as the NHS scrambled to create enough placements. This resulted in hundreds of students being relocated across the country on short notice, with many learning their exact job locations only weeks before starting.
This guarantee, however, does not extend to specialty training, such as IMT. After completing Foundation Training, doctors must choose the GP or consultant track, and apply for the relevant specialty training, a competitive process that typically begins in November for positions starting the following August. The application process is conducted nationwide, with all candidates ranked accordingly. Here, securing a job is not guaranteed.
Doctors compete for positions based on a combination of scored applications, exams and interviews, depending on their chosen specialty. Despite a growing shortage of both GPs and specialist doctors, thousands are being turned away. An astonishing 10,940 applicants were rejected for GP training last year. To take one example of a vital specialist role, nearly 3,000 applicants were rejected from core training in anaesthetics last year, with 6.5 candidates vying for each available position – compared to just two per spot in 2015.
As doctors are free to apply to as many specialty training programmes as they wish, some argue the figures are skewed by multiple applications. These are rising, and FOI data highlighted by Nathan Dumpleton shows applications per candidate stood at 1.89 in 2023, up from 1.57 in 2013. However, the data also shows a significant rise in unique applicants to specialty training, with 33,870 applicants to round one of specialty training in 2025, while the total number of applicants for all levels of specialty training in 2013 was 17,117. The increase in competition is driven almost entirely by non-UK doctors joining the workforce. According to the GMC, the number of non-UK doctors joining the workforce in 2015 stood at 5,000; in 2023, it reached nearly 20,000. In that same year, over two-thirds of joiners were non-UK graduates.
Increased competition from abroad is forcing out British graduates because, from October 2019, medical practitioners were added to the Shortage Occupation List in Britain, meaning that all medical practitioners were exempt from the Resident Labour Market Test (RLMT). Medical vacancies no longer had to be offered to UK citizens first, before being offered to foreign citizens only on the condition that no UK citizen was available or qualified to fill that role.
The problem has become so severe that the Royal College of Physicians has made it a key platform of their NextGenPhysicians campaign, which focuses heavily on the impact of increased competition ratios and calls for a rethink on British medical postgraduate training. The College is also, rightly, worried about the impact on future graduates. The number of medical training places is set to expand to 15,000 by 2031. With this expansion of training places will come a much large number of British graduates, even higher competition ratios and, potentially, even higher numbers of British medical graduates failing to secure work in the British medical system – which, as British medical students complete clinical placements in the NHS from their third year onwards – they have already worked in.
The increase in medical training places is a key part of the NHS Long Term Workforce Plan as a way to reduce the institution’s reliance on foreign-trained medical staff – a staffing solution that leaves the NHS overexposed ‘to future global shocks and fluctuations in international workforce supply’. But, as the document also notes, ‘the pace at which international recruitment can be scaled back will be contingent on the rate of expansion of and investment in domestic training and education’. It makes little sense to increase training capacity in order to reduce reliance on foreign-trained doctors, but then not prefer domestically-trained doctors for postgraduate training – particularly given the concerning statistics about the performance of foreign-trained doctors in the NHS.
Health Secretary Wes Streeting has, encouragingly, criticised the NHS for its reliance on foreign-trained employees, arguing it had been too willing to pull ‘the immigration lever’ after the Telegraph revealed that almost two-thirds of medics registering to practice medicine in Britain last year qualified abroad. Any serious attempt to prioritise what he called ‘home-grown talent’ must include re-establishing the RLMT (which was abolished altogether in 2020) for medical practitioners; it makes no sense to build a bigger conveyor belt, only to allow more students to fall off the end. We know that British-trained medical students receive some of the best medical training in the world, and already have the advantage of working in the NHS for long periods. What sane country would not prefer such candidates?
The NHS has a fearful problem with workforce retention; it might be that the first step to fixing that problem, along with ending its overreliance on an immigrant workforce, is not to leave thousands of well-trained and keen doctors in anxious, pensive stasis, wondering if they will need to relocate or retrain. The NHS’s patient problems are bad enough; can they stand such staffing problems, too?
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