Date published: 24 October, 2025
Date last updated: 24 October, 2025
Workforce

Appendix C: Desktop review: emergent themes for postgraduate medical education

This appendix forms part of the Medical Training Review: Phase 1 Diagnostic Report.

Summary

This desktop review has analysed academic studies, data from national surveys and international practice to identify the emergent themes that inform the diagnostic phase 1 of the Medical Training Review.

  • Workforce alignment. Training capacity must expand and adapt to produce the number and types of doctors the NHS needs. More training posts to remove bottlenecks and new training pathways for roles in underserviced areas should be explored.
  • Flexibility and customisation. A modern training system should accommodate different training paces and paths. Whether through competency-based progression or options to switch specialties, flexibility is key to keeping resident doctors in training and engaged. Rigid structures are giving way to personalised ones globally and the same should happen in the UK, while maintaining standards.
  • Resident doctors’ wellbeing and culture. The wellbeing of resident doctors is a prerequisite for success. Reducing burnout and workload to safe levels and rooting out bullying and discrimination are urgent actions. A positive, supportive culture is not a luxury – it directly affects learning and patient care.
  • Quality and consistency of training. Every resident doctor, regardless of location or specialty, deserves high-quality supervision and ample learning opportunities. The system should level up struggling training environments and disseminate best practices from high-performing ones. Initiatives to improve the balance between service and training (like the surgical pilot) should be expanded and trainers must be supported with time and training to fulfil their roles.
  • Generalism and specialism balance. Training must produce doctors with broad capabilities as well as specialist expertise. Reforms should continue to strengthen foundational generalist training and create pathways for additional specialisation where needed. The outcome should be consultants who are adaptable – a quality needed in evolving healthcare landscapes.
  • Learning from global best practices. The UK should learn from international exemplars, including Canada’s competency-based curriculum, the USA’s investment in residency infrastructure and Australia’s targeted rural training models.

However, important evidence gaps remain. While there is extensive literature on training structures and trainee experience, high-quality data on the outcomes of different rotation models – for example, the risks and benefits of frequent rotations versus greater geographical stability – are limited.

Similarly, while international innovations such as competency-based curricula (Canada’s competence by design; Hall et al, 2024) and rural generalist pathways offer valuable insights, peer-reviewed evaluations of their long-term impacts on trainee competence, workforce retention and patient outcomes are still emerging (Hall et al, 2024).

Addressing these gaps through targeted research and ongoing evaluation of reforms will be essential to ensure that future changes to UK PGME are grounded in robust evidence and aligned with the needs of patients, the NHS and trainees themselves.

The UK’s PGME system has much worth preserving, but it also faces modern challenges. By addressing the emergent themes presented in this desktop review to make training more flexible, humane and aligned with healthcare needs, PGME in the UK will remain among the best in the world. The goal is a postgraduate training system that produces skilled, confident and resilient consultants and GPs capable of leading the NHS forward.

Introduction

Postgraduate medical education (PGME) is the critical bridge between medical school and independent practice. In the UK and globally, this training has undergone incremental change over the past decade, driven by evolving patient needs, workforce pressures and educational innovation (Patel, 2016).

This report is the output of a desktop review completed to complement a literature review, to diagnose the state of UK PGME, identify gaps in the literature review and highlight emergent themes. Both peer-reviewed studies and grey literature (policy reports, surveys and expert position papers) from the UK and internationally over a 10-year period (2015–2025) have been included. The findings informed the phase 1 diagnostic report.

For the purposes of this appendix, resident doctors include both those in formal training programmes (postgraduate doctors in training) and locally employed doctors (LEDs).

The literature search completed by NHS England’s Knowledge Management Team provided a broad review of UK and international literature relevant to PGME from 1993 to the present.

However, this desktop review identified and addressed several gaps:

  • recent pandemic-era transformations: recent literature on how Covid-19 accelerated changes in teaching methods and resident doctor support was not sufficiently explored; this emphasises the adoption of remote learning, technology in education and the need for more attention to resident doctor wellbeing post-pandemic (Altintas et al, 2024)
  • international models and competency-based medical education (CBME): CBME developments abroad (for example, in the USA, Canada and Europe) were missing; studies highlight the implementation challenges and paradoxes of CBME in residency training (Birman et al, 2024), and global trends like entrustable professional activities (EPAs) and milestones that could inform UK practice (Weggemans et al, 2017)
  • grey literature and surveys: key reports from bodies like the General Medical Council (GMC), Royal Colleges and think tanks (The King’s Fund, Nuffield Trust) were not included; these provide up-to-date data on resident doctor and trainer experiences (for example, burnout rates and discrimination) and policy-level perspectives on necessary reforms

Additional recent sources that are now included are:

By filling these gaps, the desktop review presents a comprehensive overview of current challenges and successes in PGME, organised by key thematic areas.

Current landscape of UK postgraduate training

The UK’s PGME system has seen numerous changes in structure and oversight since the early 2000s. The result has been a more standardised and structured training pathway with defined outcomes, from the 2-year foundation programme through specialty training. Reforms like Modernising Medical Careers and the establishment of Health Education England (HEE) as a statutory education body and local education and training boards aimed to create a national framework for training.

Indeed, compared to the past, today’s resident doctors in postgraduate training programmes follow curricula with explicit capabilities and competencies and undergo regular workplace-based assessments and annual reviews (ARCPs), to deliver consistency across the country (Patel, 2016).

One success is the foundation programme, introduced in 2005. Despite early criticism, it is now “viewed quite positively” as a structured bridge from medical school, providing broad clinical exposure and basic professional skills to all new doctors. This universal foundation is a strength of the UK system, ensuring every resident doctor meets core competencies before specialisation. Likewise, the UK has been a leader in mandating accreditation for medical educators. Since the mid-2010s, consultants must be approved as trainers, which has professionalised supervision and teaching roles in many hospitals. This is referenced as a key development in contemporary literature (Patel, 2016).

Importantly, training quality in the UK remains high by many measures. The GMC’s annual national training survey consistently shows most resident doctors are satisfied with their training and feel they are acquiring the necessary skills. For example, in 2024 over 80% of resident doctors in training programmes rated their clinical supervision positively and most would recommend their post to a friend, indicating that, overall, educational standards are being maintained even in a pressured health service.

UK-trained specialists and GPs are recognised internationally for their strong clinical skills and professionalism, reflecting well on the curricula and assessments set by Royal Colleges.

At the same time, it is evident that this progress has come with new constraints and tensions. The drive to standardise and shorten training, partly in response to workforce needs and the European Working Time Directive, means today’s resident doctors have fewer years and fewer hours per week to gain experience (Patel, 2016). Many feel pressured or underprepared at the end of training, especially those in the craft specialties.

The 48-hour working week limit imposed by the directive, while improving work–life balance, has led surgical resident doctors for instance to report insufficient operative exposure. A survey by the Association of Surgeons in Training found most would support opting out of hour limits to get more training opportunities. Thus, even though ‘time for training’ has been protected on paper, in practice balancing service and education remains challenging (Bates et al, 2007).

In summary, PGME in the UK has strengths including a well-organised training structure, clear outcomes and dedicated educators, but also significant challenges to overcome. This desktop review highlights the following emergent themes and explores what needs to change and what must be preserved or enhanced, drawing on both UK and international insights.

Emergent themes: challenges and opportunities

1. Training capacity and workforce pressures

A dominant theme is the mismatch between workforce needs and training capacity. The UK is trying to rapidly expand its medical workforce, but training bottlenecks present a strategic concern. The Royal College of Physicians (RCP, 2025) notes that only 1 in 4 applicants to internal medicine training currently secures a training post – “thousands of UK doctors every year are unable to continue their medical career in an NHS training post” due to limited slots. This high competition leaves many qualified graduates in roles that are primarily service delivery focused. The RCP and others have been calling for a long-term commitment to expand training numbers in line with population health needs (RCP, 2025).

Limited training posts have led to rising numbers of LEDs or trust-grade doctors, where doctors work outside formal PGME training programmes. Many choose these roles for more flexibility or to avoid repeated relocations (The Kings Fund, 2024), which is explored in more detail later in this report. However, LEDs often report poor access to training and career development and feeling like second-class citizens with “lack of recognition” in the system (The King’s Fund, 2024). This suggests the training pathway needs to be scaled up or made more flexible to accommodate more doctors and retain talent and address staff shortages.

Another workforce pressure is the geographical maldistribution and rotation burden. Currently, UK resident doctors typically rotate through different hospitals (often in different cities or regions) every 6–12 months, especially in earlier years. While this provides breadth of experience, it can be highly disruptive to personal life, contributing to stress and even deterring some from entering training. This has been identified both by NHS England (Amanda Pritchard’s letter April 2024) and in the non-pay agreement (2024) between the British Medical Association and Department of Health and Social Care, triggering a review of the rotation model.

NHS England’s Medical Training Review has already stated that it will consider placement options to see if training can be delivered in a less peripatetic way. Other countries’ models suggest possible alternatives: for example, US resident doctors generally stay in one hospital for the duration of their training, offering more stability though potentially at the cost of varied exposure.

Finding the right balance between breadth of experience and stability during PGME is key. Many have proposed longer rotations or regional consolidation of placements to reduce the frequency of moves, especially for those with families or other responsibilities. Indeed, one reason many doctors opt for more service delivery focused jobs is to avoid having to “move to different areas” annually (The Kings Fund, 2024).

Geographically stable training programmes or improved relocation support could be considered to improve recruitment to and retention in PGME training posts.

Finally, service workload pressures in the NHS inevitably spill into training capacity. When hospitals are understaffed, resident doctors often act as frontline workforce to keep services running, which can impinge on training opportunities. There is, however, a perception that service and training are entirely distinct, with the opportunity to consider how experiential learning and better training within service environments could reduce the impact of service commitments on training.

Educators and trainers also report being stretched thin. The GMC warns that plans to expand medical school intakes will falter unless the needs of trainers are addressed: in 2024, half of all consultant trainers reported being at high or moderate risk of burnout and nearly a third struggled to make time for training duties alongside clinical work (GMC, 2024). Protecting time for supervision and teaching is increasingly recognised as a requirement to accommodate more resident doctors without diluting educational quality (GMC, 2024).

The literature paints a clear picture: to expand the medical workforce, training capacity must also be expanded. More training posts, more educators, taking advantage of technological advances, innovative supervisory and blended-learning approaches all provide opportunities to secure the medical workforce pipeline.

2. Flexibility and personalisation of training pathways

Since the introduction of Modernising Medical Careers, UK postgraduate training has been quite linear and rigid. Resident doctors typically commit to their chosen clinical specialty early in their career and follow a fixed curriculum and timetable to completion.

A clear emergent theme is the desire for greater flexibility in training pathways, to accommodate individual autonomy, career goals, life events and evolving service needs. This includes flexibility in training duration, training intensity and the ability to change specialty.

One aspect is less than full-time (LTFT) training, which has become more common in the past decade as doctors seek a better work–life balance or need to manage family and health obligations. The UK has made strides here: policies now allow resident doctors to work flexibly for caregiving, health or wellbeing reasons, which is a positive development often highlighted in NHS staff support strategies. However, resident doctors working LTFT still report administrative hurdles and stigma in some cases.

Ensuring parity of experience for LTFT resident doctors (for example, access to opportunities and not feeling like an afterthought in rota planning) is an area for continued improvement noted in qualitative reports. Service providers also report challenges in managing rotas and work schedules where resident doctors opt to work flexibly and cite lack of consultation about the impact and financial constraints as issues.

Another facet is the ability to pause or redirect PGME training. Career flexibility was a key recommendation of the Shape of training review (2013), which advocated for training models that produce more broadly trained doctors with options to credential in subspecialties later. Similarly, the Future Doctor report and the Chief Medical Officer’s annual report 2021 highlight the need for a workforce that has the capabilities to care for a multimorbid population and to respond to significant health challenges (as exemplified by the Covid-19 pandemic), as well as the specialist skills to provide excellent care in a high technology medical environment.

The GMC has introduced a framework for credentialing in specific areas of practice (outside the core Certificate of Completion of Training, CCT) and some specialties are piloting more modular training. Yet, resident doctors still find it difficult to switch clinical specialties or transfer skills between training programmes. Often, they must start again if they change direction, which can deter exploration and lock people into specialty choices.

In contrast, in the US system, many physicians do a core residency (for example, internal medicine or general surgery) and then subspecialise via fellowships, which allows a natural branching point. Similarly, Canada’s new competence by design (CBD) model explicitly contemplates variable pacing, supporting fast progress for those who achieve competencies quicker and extended training for those who need more time (Birman et al, 2024; Frank et al, 2024).

The UK could adapt elements of these approaches by building more flexibility into ARCP outcomes (for example, allowing accelerated progression or targeted extension without stigma) and facilitating switching between related training programmes with credit for prior experience.

Crucially, flexibility must also address the cost and length of training, as noted by the RCP’s Resident Doctor Committee. They highlight that lengthy training paths (often a decade or more after medical school for certain specialties) and high costs (examination fees, courses, relocation costs) are a source of frustration (RCP, 2025).

A more personalised approach might support an outstanding resident doctor to finish sooner (saving a year or 2 of time and expense) or allow resident doctors to step out into a research or management fellowship and return without penalty.

Embracing the concept of a ‘portfolio career’ within training – where doctors can gain additional skills (for example, in leadership, academia, clinical informatics or a different specialty) and not be seen as going off-track – would modernise the training paradigm.

Encouragingly, initiatives like academic clinical fellowships and integrated clinical/academic training pathways, flexible portfolio training and chief registrar schemes already exist to blend roles, but these could be expanded.

In summary, literature and policy commentary converge on the point that one size does not fit all in medical training. Greater flexibility and personalisation would improve morale and potentially attract a more diverse range of doctors to complete specialist training.

International CBME trends, where progression is based on demonstrating abilities rather than time served, also reinforce the move towards a more individualised training journey (Birman et al, 2024). The challenge will be implementing PGME flexibility while maintaining fairness and standards.

3. Working conditions, wellbeing and culture

The integral nature of resident doctors’ wellbeing and training quality is well established in the literature. Over the past decade, especially since the Covid-19 pandemic, a wealth of data has emerged highlighting issues of burnout, mental wellbeing and workplace culture among resident doctors. Addressing these is critical to retaining resident doctors and enabling them to learn effectively.

Burnout was a recurring theme through this desktop review. Surveys show high levels of emotional exhaustion and stress among resident doctors, often linked to excessive workloads and long shifts.

In the 2024 GMC national training survey, 1 in 4 UK resident doctors reported being at moderate or high risk of burnout and in some acute specialties the figures are even more alarming. Emergency medicine is an illustrative case: one-third of emergency medicine resident doctors reported high burnout risk, compared to 25% across all specialties, and a striking 72% described their workload as “heavy or very heavy”. Rota gaps, high patient volumes and the added pandemic-era pressures (backlogs and long waiting lists) are all contributing to resident doctor burnout (RCEM, 2024).

The reported risk of burnout among doctors in training is a significant concern. This has led to a notable proportion reducing their working hours or considering leaving the profession, underscoring the need for PGME reforms that promote sustainable working patterns and adequate rest (GMC, 2024; The Guardian, 2024).

Another critical aspect of culture is the prevalence of bullying, harassment and discrimination. Unfortunately, recent surveys have shed light on unprofessional behaviours that persist in some training environments. For instance, 2023/24 data revealed that 15% of female and 5% of male emergency medicine resident doctors had experienced unwelcome sexual comments or advances during training – the second-highest rate across all specialties, with obstetrics and gynaecology reporting the highest (RCEM, 2024). Additionally, resident doctors from ethnic minority backgrounds, those who trained outside the UK and those with protected characteristics report higher rates of discrimination and are less confident in reporting it (RCEM, 2024).

Surgical resident doctors have raised concerns about an “old boys’ club” culture. The Royal College of Surgeons of Edinburgh expressed grave concern at 2023 findings of 1 in 10 surgical resident doctors encountering sexual harassment and many more witnessing or experiencing bullying. Such a culture is clearly detrimental to training and mental wellbeing. Tackling this requires strong institutional action: zero-tolerance policies, easy and safe reporting mechanisms and positive role modelling by senior staff. There is also a need for greater diversity in leadership and faculty to drive an inclusive culture.

The King’s Fund identifies wellbeing initiatives implemented through NHS England programmes like Enhancing doctors’ working lives and a charter on improving facilities (for example, rest spaces and access to food and water on shifts) as immediate actions to improve retention (The Kings Fund, 2024).

The pandemic led to more open conversations about mental health support for doctors, with many organisations expanding counselling and mentoring for resident doctors. However, anecdotal reports suggest that, in the face of financial constraint, staff support programmes are being scaled back. Studies during Covid-19 highlighted the importance of resilience and support systems; for example, a 2024 review underscored integrating mental health and resilience training into curricula (Altintas et al, 2024). This is a practice some international programmes have embraced, such as resident wellness curricula and protected time for wellbeing activities in certain US residencies.

Creating a healthy training culture is both a moral imperative and a practical necessity to sustain the workforce. Ensuring resident doctors are valued team members and that a compassionate training culture is embedded throughout PGME is a direct investment in the quality of patient care.

4. Quality of training and supervision

While the UK boasts strong curricula and assessments, there is notable variability in the quality of training experiences across different regions and specialties. Ensuring consistent high-quality supervision and adequate clinical exposure for all resident doctors was a consistent challenge identified in the desktop review.

One issue is variable supervision and teaching. Resident doctors report that the calibre of training depends on the hospital or department they are placed in. The RCP (2025) highlighted “hugely variable quality of supervision” as a concern impacting on resident doctors. In practical terms, some training units provide regular teaching, feedback and mentorship, while others offer little protected teaching time and only sporadic feedback, often due to service pressures. GMC national training survey data shows some units consistently score as outliers (positive or negative) on indicators like clinical supervision and supportive environment.

To address this, experts call for strengthened accountability and support for training sites. The UK’s system of deaneries and local education and training boards (now integrated under NHS England) and the GMC’s quality assurance visits need to uphold standards and intervene when training is subpar. Better incentivisation of NHS organisations to prioritise education – for example, by linking funding to training outcomes or providing additional resources to struggling programmes – should be explored.

Another important facet is the balance of service and training. Reports such as Time for training (2010) warned that if resident doctors spend excessive time on service tasks that do not meaningfully contribute to learning, their skills development may be compromised. However, not all service work is of equal educational value and its impact on training may vary:

  • administrative and clerical tasks (for example, routine documentation, discharge summaries, chasing results) offer minimal clinical learning value, although they can help develop professional skills such as organisation and communication
  • repetitive clinical tasks (for example, routine venepuncture or cannulation) may offer limited specialty-specific training yet still contribute to procedural confidence and interaction with patients
  • patient-facing acute clinical service (for example, on-call shifts, out-of-hours work, emergency care) often disrupts access to formal specialty training opportunities but can provide rich experiential learning, particularly in decision-making, teamworking, communication and managing clinical uncertainty

While educational benefit may be derived from many types of service work, concern remains where training progression relies on acquiring complex specialty skills as this can be crowded out by disproportionate service delivery responsibilities. Striking the right balance – protecting access to specialty-specific learning while valuing the role of experiential and generalist patient care – is central to postgraduate education reform.

The balance of service versus training remains a pain point in some specialties. Surgical and acute care resident doctors often cite being pulled into covering rota gaps or doing excessive administrative work, leaving less time for supervised surgeries or clinics.

The Improving Surgical Training (IST) pilot was one initiative to address this. It sought to create a better balance by redesigning rotas, enhancing supervision (including assigning dedicated trainers to surgical resident doctors) and integrating simulation training. The evaluation of IST showed some promising signs. IST resident doctors as a cohort achieved more operative experience and progressed faster in certain competencies than non-IST peers (SQW, 2022). This suggests that when training is conscientiously structured (with protected teaching time, simulation, etc), outcomes improve.

However, the evaluation also flagged challenges: not all pilot sites fully implemented the model, risking a “two-tier system” where some hospitals excelled in training and others lagged behind. A lesson here is that system-wide improvement is needed, not just isolated pockets of excellence; that requires alignment of incentives so that every hospital sees training as core business, not an optional extra.

The theme of resident doctors’ autonomy and responsibility also emerged under quality. Paradoxically, while resident doctors do not want to be exploited for service, they do want meaningful responsibility in patient care as they advance. Research in medical education suggests that a graded increase in responsibility is crucial for CCT readiness (Sterkenburg et al, 2010; Cate et al, 2016). Yet, supervisors may withhold independence due to concerns about errors or service pressures, potentially impeding resident doctors’ decision-making development. Encouraging a culture of entrustment, where resident doctors are entrusted with tasks as soon as they are capable (echoing the concept of entrustable professional activities, EPAs), can improve both confidence and competence. The international move towards EPAs is primarily about incorporating entrustment in training (Kumar et al, 2022). The UK’s newer curricula have begun to incorporate ‘capabilities in practice’, which parallel EPAs and aim to clearly define what a doctor should be able to do at each stage and entrust them accordingly.

Educational innovation is a positive feature reported in the literature for improving quality. The pandemic forced a rapid expansion of virtual learning, simulation and online assessment and these have now become mainstay. Multidisciplinary simulation exercises, video review of procedures and e-learning modules have been shown to enhance learning when used appropriately (Cate et al, 2021). The literature suggests that blending these with traditional training can accelerate skill acquisition. Formal faculty development for educators is recognised as vital for quality. The UK has numerous courses and postgraduate certificates in medical education that should continue and expand.

Ensuring high-quality training for every resident doctor requires uplifting the poorer performing units (through oversight, resource support and accountability) and simultaneously innovating and spreading best practices from the high performers. The outcome should be a more uniformly excellent training experience, which in turn produces confident, well-prepared new consultants across all regions and specialties.

5. Balancing generalist and specialist expertise

Modern healthcare needs doctors who are both highly skilled in specific areas and yet able to work across specialties to manage complex patient needs (Whitty, 2023). How to achieve the right balance between specialist knowledge and broad, generalist skills in training has been a subject of debate and was a central concern of the Shape of training review. Over the past decade, the pendulum has been swinging towards more generalism in early training, with specialisation coming later, but this shift brings its own challenges and lessons.

The impetus for more generalist training comes from real-world changes: an ageing population with multimorbidity means highly specialised doctors may struggle to manage the whole patient. Reports like The future hospital (2013) and Shape of training (2013) argued that the UK needed more doctors trained broadly.

The need for broader training led to reforms such as the creation of internal medicine training, a new 3-year programme from 2019 that replaced core medical training. This gives all medical registrars training in general internal medicine including critical care, so that when they enter specialty registrar years they have a solid generalist foundation. Similar trends are seen in paediatrics and other fields, where training is now broader (community and hospital multidisciplinary exposure).

The foundation programme was designed to produce doctors with generalist competencies that can then be applied to any specialist field.

These changes are viewed positively in principle but raise concerns around shortening or diluting specialist training. Many resident doctors worry that with fewer years devoted to the specialisation, they may finish training less confident in advanced aspects of their field. This sentiment has been echoed by resident doctor associations. Striking the balance between not over-lengthening training and ensuring depth of expertise remains complex.

Potential solutions discussed in the literature include post-CCT fellowships or credentialing to top up skills in narrower areas and ensuring robust continuing professional development after training so that new consultants and GPs can continue developing while in their roles.

Useful international insights are provided from the USA and Canada, where generalist and specialist skill acquisition is approached by requiring a broad residency (like internal medicine or general surgery) followed by optional fellowships. This inherently produces many ‘generalists’ (for example, hospitalists in the USA are essentially internal medicine residency graduates without fellowship) while also allowing those who want to be highly specialised (for example, a cardiologist) to pursue extra training.

The Netherlands and some other European countries have embraced competency-based models that allow flexibility in training length. A resident doctor demonstrating competence in general areas can move more quickly into a chosen specialist focus.

These approaches underline the value of defining clear outcomes for both generalist and specialist roles. The UK’s generic professional capabilities framework (launched by the GMC in 2017) aims to articulate the universal skills (communication, leadership, patient safety, etc) that every doctor must have, complementing and contextualising their specialty-specific skills. This is very much in line with global best practice and should continue to be a cornerstone of curricula.

One area where tension between generalist and specialist is particularly visible is in the division between hospital and community-based training. The UK, like many countries, faces a need for more clinicians who are equipped to manage complex multimorbidity and deliver care across a range of settings, including primary care, hospitals and community services. It will be important to ensure that hospital training programmes do not unintentionally narrow trainee experience to highly specialised environments and conversely that those pursuing careers in community and general practice have sufficient acute and hospital experience.

The foundation programme and initiatives like combined training rotations (for example, paediatricians undertaking community placements or physicians gaining exposure to GP settings) help develop generalist capabilities across the workforce. Some commentary suggests that developing broader “generalist credentials” – for example, in acute care, frailty or mental health – could offer doctors in many specialties the opportunity to acquire cross-cutting skills applicable to a range of patient populations.

The literature supports acquisition of generalist skills in the early years of PGME as a response to healthcare needs (Greenaway, 2013; Patel, 2016). The key is not to lose the excellence in specialised expertise that UK consultants are known for. Careful curriculum design may enable the best of both: doctors with a strong generalist grounding and advanced specialist capabilities. Other countries’ experiences show this is possible, but it requires clear definition of competencies and, often, a re-imagination of the later stages of training and early consultant years as a continuum of learning.

6. Lessons from international models

No country has a perfect postgraduate training system; all are trying to adapt to similar challenges. However, valuable lessons for the UK emerge from international models:

  • Competency-based training and outcomes. As discussed, many nations (Canada, the USA, the Netherlands and Australia) are implementing CBME reforms. Canada’s competence by design initiative is especially noteworthy as a national transformation across all specialties, introducing milestones and EPAs with the idea of time-variable training (Kumar et al, 2022; Frank et al, 2024). Early reports suggest this has been met with cautious optimism but also highlight the need for faculty development and cultural change to succeed (Birman et al, 2024). The emphasis should be on assessment for learning (using tools to give feedback and guide resident doctors) rather than tick-box exercises, a lesson echoed in international literature on workplace-based assessments.
  • Structured mentorship and support. In the USA, residency programmes often have formal mentorship schemes and resident wellness committees. Some also embed mental health professionals in training programmes to provide confidential support. The importance of this has been recognised globally, especially post Covid-19 (Altintas et al, 2024). Formalised mentorship, specifically outside the resident doctor’s direct line management, has been shown in some countries to help resident doctors navigate career choices and personal challenges. Additionally, coaching programmes for resident doctors (already piloted in a few UK deaneries) draw on successful models in Canada and the Netherlands where coaches aid reflective practice and career development.
  • Resource investment in training. In the USA, PGME is heavily funded (through Medicare and hospitals), which, for all its complexity, means residents are a recognised expense line and hospitals compete for resident doctors by offering education resources. While the US system has its own inefficiencies, one takeaway is that funding and accountability for training should be clear. The UK’s centrally funded model could incorporate some of this by more transparently linking funds to training outcomes and requiring NHS trust boards to account for resident doctor satisfaction and success as key performance indicators. Germany provides a contrast: its PGME has been criticised for lack of national co-ordination and quality control, prompting young doctors there to call for an overhaul including a national PGME body (Hahn, 2024). The UK is fortunate to have national structures; strengthening their role and resourcing (perhaps akin to how Australia has a national training accreditation for all components of medical careers through the Australian Medical Council) could further improve consistency.
  • Innovations in delivery. Several countries had experimented with technology and alternative training methods even before Covid-19. For instance, simulation training centres in Canada have become integral for procedural skills development; one Israeli study notes simulation and flexibility as keys to modern training (Ziv, 2006). During the pandemic, tele-education and virtual case discussions became routine across the globe (Altintas et al, 2024). The UK can build on this by continuing blended learning – for example, national online lecture series for rare topics and virtual reality simulations for emergency scenarios – ensuring resident doctors from all regions have access to high-quality learning materials. Moreover, global health rotations or exchanges are something other countries use to broaden resident doctors’ perspectives; a structured exchange programme could allow UK resident doctors to learn from different health systems and bring back ideas.
  • Flexible career models. Some nations have created alternative pathways that the UK could adapt. For example, Australia’s rural generalist pathway trains doctors in a mix of general practice and additional skills (for example, in obstetrics or anaesthetics) to serve in rural areas – a targeted approach to workforce needs. The UK might consider similar targeted training schemes (akin to NHS England’s enhancing generalist skills programme). Dual-training programmes are another concept: in the USA, combined residency programmes (like medicine–paediatrics or psychiatry–neurology) produce physicians board-certified in 2 fields. The UK could offer more dual CCT options (some exist – for example, general practice and public health) to create a flexible workforce that can cover interdisciplinary fields.

In essence, the international lesson is that adaptability is key. Countries that have made strides foster a mindset that training is a continuous, evolving process with regular feedback loops, willingness to change curricula and a focus on the learner as much as on the system. The Medical Training Review is an opportunity to incorporate these global best practices and avoid pitfalls others have encountered. By benchmarking against other high-performing systems and staying engaged in international medical education collaborations, the UK can ensure its postgraduate training remains world-class and forward-looking.

Strengths to build on

While PGME reform discussions will inevitably focus on problems, it is important to recognise what the UK is doing right and to build on these strengths for future improvements:

  • Structured curriculum and clear standards. The UK’s training programmes are highly structured with defined curricula, examinations (for example, membership examinations for Royal Colleges) and competency frameworks. This ensures consistent outcomes and patient safety. UK-trained consultants are respected globally, indicating that current standards produce doctors with strong knowledge and skills. Training is outcomes-focused, with definitive endpoints (CCT) that signal readiness for independent practice (Patel, 2016). The core principles of this structured approach should be retained as flexibility is increased; it anchors the system and maintains quality control.
  • Foundation programme success. Now over 15 years old, the 2-year foundation programme has demonstrated elements of success, including providing a universal base of core clinical competences for all new doctors, improved transitions from medical school and exposure to a mix of specialties and community placements early in careers (Patel, 2016). As noted in Shape of training, it is a platform to build on and proposals to enhance it, like more community and public health experience, can leverage an established model.
  • National oversight and quality assurance. The GMC, NHS England Workforce, Training and Education and the medical Royal Colleges provide a robust framework for monitoring and improving training quality. The GMC national training survey is a powerful tool that many countries lack. Tens of thousands of resident doctors and trainers give feedback annually, leading to identification of key issues and highlighting excellent training environments. This commitment to self-audit and transparency is a strength (GMC, 2024). It means the UK can detect issues like burnout or harassment early and respond. Moreover, the requirement for trainers to be approved and the existence of training programme directors and deanery structures ensure there is accountability. Many international systems have far less formalised postgraduate training structure and governance; the UK should continue to lead in having dedicated educational governance.
  • Dedicated educators and innovation. The UK benefits from a community of dedicated medical educators with many consultants giving significant time to training. Many resident doctors engage in education and leadership fellowships, and NHS leadership and organisations like the Academy of Medical Royal Colleges and GMC have been supportive of innovation. Examples like the IST pilot, credentialing pilots and various digital education projects show a willingness to experiment and improve. The fact that the majority of trainers (90%) still report enjoying teaching despite their workload (GMC, 2024) is a testament to the vocational commitment in the system. Leveraging this enthusiasm through better support (protected time, training for trainers) will be important, but the human resource – people who care about education – is a big asset.
  • Adaptability shown during Covid-19. The pandemic forced rapid adaptation in postgraduate training: from redeploying resident doctors, to implementing remote teaching and exams, to accelerating independent practice for senior resident doctors when consultants were stretched. The system showed it could adapt under pressure, with many of those adaptations, like online clinics or virtual simulation, proving useful beyond the crisis. This agility is a strength to harness – for instance, continuing to use the tele-supervision or simulation training that was ramped up in 2020 and 2021 can improve training efficiency and access (Altintas et al, 2024).
  • Global recognition and collaboration. UK postgraduate qualifications (like MRCP and MRCS) and the CCT are recognised in many parts of the world, reflecting a trust in the UK’s training quality. The UK also contributes to global medical education through research and partnerships. Many international medical graduates come to the UK for training and UK educators influence global standards via organisations like the World Federation for Medical Education. This position allows the UK to be a leader in PGME reform and to exchange ideas with other countries.

The UK’s PGME system has firm foundations of excellence, structure, governance and commitment from educators. Reforms should build on these strengths by refining and evolving a good system to make it fully future proof.

Publication reference: PRN01835

Date published: 24 October, 2025
Date last updated: 24 October, 2025