- David Oliver, consultant in geriatrics and acute general medicine
- davidoliver372{at}googlemail.com
Follow David on Twitter @mancunianmedic
On 24 October NHS England published the first phase of a review of the state of UK medical training.1 This “diagnostic” report has been badged as the starting point for a programme of reform in postgraduate medical education, training, and career structures.
Although the report offers 11 key recommendations for change, it provides no plan, resources, or timeline to achieve them. It also tries to balance the priorities and needs of doctors in postgraduate training posts with the change required to meet the needs of a modern patient population and the government’s ambitions to shift more care outside hospital—yet it’s not clear how it will reconcile these needs.
The report draws on detailed data from engagement exercises and surveys about what doctors in postgraduate training say about their experiences, what they value and find frustrating in the current system, and the positive changes they want to see. This is a useful starting point. After all, if we don’t fix the problems that are making doctors at training grade or those in specialist, associate specialist, and specialty (SAS) roles unhappy, we won’t fix the NHS’s current crisis in staff morale and retention, which in turn affects the supply of future GPs and consultants.
High on the list of doctors’ concerns are the competition ratios for specialty training pathways; the percentage of international medical graduates applying for training posts; the growing employment of SAS and locally employed doctors (which helps with service provision and team stability but could remove employers’ need to expand the number of training posts); and inequalities between ethnic groups in career progression and exam success.
The doctor’s eye perspective is balanced in the report with some key issues that the health and care system must tackle to make services and staff fit to care for the UK’s current and future population. An ageing population and more multiple long term conditions mean that good “expert generalist” training and skills, integrated multidisciplinary care in community settings, and easy access to local care and expertise are all increasingly important.
Modern population needs
There are some tensions here between service needs and what doctors want from their career. Above all, doctors in the report prized the ability to train in the specialty of their choice (as the more specialised disciplines have higher competition ratios than generalist ones) and the region of their choice. To reconcile patients’ needs with doctors’ preferences, policy makers will need to make the less popular disciplines and regions more desirable by improving the quality of training experiences. The curriculum and teaching priorities in medical school should also be reshaped to reflect modern population needs and a greater focus on multimorbidity and community based care, rather than single disease approaches.
The report omits some key issues. One is pay—a reasonable exclusion, since this is settled by negotiation between doctors’ unions and the government. Another is the growing use of physician assistants and advanced clinical practitioners. Doctors have been vocal in arguing that this policy risks harming doctors’ training opportunities. Ignoring this key concern is a missed opportunity that won’t help the report’s credibility.
Finally, despite the review making 11 separate recommendations for change, there’s no delivery plan, no explicit reference in the “Next steps” section to a timeline or when phase 2 of the plan will be published, and no detail on how the NHS will get the funding to make this happen. The report underlines the “urgency” of its recommendations, which include tackling training bottlenecks and the ratio of home grown to international medical graduates. This urgency is warranted given the recent expansion of UK medical school places, which has so far been unmatched by any funded expansion of specialty training placements beyond vague government pledges of an extra 1000 posts—a drop in the ocean next to the 74 000 doctors currently in rotational training posts in England.
The government has already scrapped the 2023 NHS long term workforce plan,2 stripping out the pledge to expand the clinical workforce and choosing instead to focus on productivity and working smarter. The planned publication of the new workforce plan for 2025 has now been postponed,3 leaving us with no concrete delivery mechanism, costing, or financial pledges.
Training and provision
Among the diagnostic review’s other recommendations are “more flexible” training routes, a better balance between training and service provision (although training has always involved an element of learning by doing, and the difference isn’t clearly delineated here), improving clinical academic career pathways, and making rotations more stable and less disruptive.
All of this is admirable, eminently sensible, and largely based on what doctors themselves say that they value, but none of it will happen without a fully funded delivery plan and timeline. Nor can this reform be isolated from wider workforce planning that affects other clinical professions or without also looking at the working patterns and retention of senior doctors. Such a plan is currently lacking—and we need one soon, if this diagnostic review is to become more than just a set of worthy ambitions.
