Approach

Between April and June 2025, 23 roundtables and focus groups provided opportunity to engage with key stakeholder groups on issues relevant to their perspectives and experiences of the current challenges within postgraduate medical education (PGME).

Reforms will only succeed if they are supported by doctors and serve the needs of patients and the wider healthcare system. It is therefore essential to build understanding of, and support for, both the need and the scope of reform through a process of engagement with multiple stakeholders.

Plus 2 deliberative townhall style events that play back early findings:

• 19 June 3pm–5pm – 141 attended
• 25 June 11am–1pm – 240 attended

Specialist, associate specialist and specialty (SAS) doctors

Why SAS posts are chosen

• Flexibility and work–life balance are major draws – SAS roles allow for job plan negotiation and geographical stability
• Career autonomy: SAS doctors can pursue teaching, niche specialties or eventually consultant roles via portfolio pathways
• International medical graduates (IMGs) often default to SAS roles due to barriers in entering formal training
• Changing perceptions: SAS roles are increasingly seen as respected and viable career paths, though stigma still exists in some areas
• Neurodiversity and diversity: SAS roles attract a diverse workforce, including more women and IMGs

Barriers to training and progression

• Lack of standardisation across trusts and departments
• Limited understanding of SAS roles by HR, leadership and even SAS doctors themselves
• Cultural and systemic issues: hierarchies, exclusion from leadership roles and undervaluation of SAS contributions
• Inconsistent access to training, mentorship and funding
• Portfolio pathway is seen as burdensome and unsupported
• Gender and racial inequalities are more pronounced in SAS roles

Training model limitations

• Current training models overlook SAS doctors – no structured pathway or recognition
• Supporting professional activities (SPAs) are often not protected or valued
• Deaneries prioritise trainees, leaving SAS doctors with fewer opportunities
• Appraisals and personal development plans are inconsistently applied or ineffective
• Job planning lacks consistency and often excludes development time

Role in future NHS needs

• SAS doctors can:
  • support community care through clinics and subspecialty services
  • lead virtual clinics and adopt new technologies (for example, AI, robotics)
  • contribute to preventative care via education and outreach
  • provide continuity and stability in the workforce
• Barriers remain in autonomy, recognition and integration into primary care or leadership roles

Recommendations for change

• Universal education on SAS roles and contracts across the NHS
• Recognition and value: financial, professional and cultural
• Single pay spine with automatic progression based on criteria
• Representation: SAS doctors should have seats at decision-making tables
• Structured development pathways with clear progression to specialist grade
• Cultural change: address gradisim, promote inclusion and shift mindsets
• Trust accountability: clear responsibilities for SAS development and leadership

Locally employed doctors (LEDs)

Motivations for choosing LED roles

• Flexibility and stability: many choose LED roles for lifestyle reasons (for example, family, avoiding relocation)
• Exploration and experience: some use LED roles to explore specialties or gain experience before applying for training
• Limited options: others, especially IMGs, take LED roles due to visa issues or bottlenecks in training pathways
• Autonomy: foundation doctors seek more autonomy and experience through LED roles

Training and development gaps

• Lack of standardisation: training opportunities vary widely across trusts; no national charter or contract exists
• Inconsistent support: some LEDs receive robust support, others none – often used solely for service provision
• Need for policy change: a national charter and dedicated funding for LED tutors are recommended

Inclusion and cultural integration

• Cultural awareness: lack of training for supervisors and staff; IMGs may not ask for support due to cultural norms
• Induction and onboarding: inconsistent or absent induction processes hinder integration and understanding of NHS systems
• Perception issues: LEDs are often misunderstood or lumped together with IMGs, leading to stereotyping and inequity
• Tailored support: emphasis on individualised support, mentorship and recognising the value LEDs bring

Role of LEDs in NHS evolution

• Community care: potential for LEDs to support community and preventative care, but currently underused
• Technology and prevention: LEDs could contribute to digital transformation and public health but are not yet integrated into these areas
• Flexibility of LED posts: LED roles can be adapted more quickly than training posts, offering strategic workforce opportunities

Recommendations for improvement

• For IMGs:
  • buddy systems, shadowing and supernumerary periods
  • mentorship and tailored induction
• At trust level:
  • appoint LED reps and tutors
  • standardise contracts and support structures
• Education and career development:
  • include study leave, SPA time and access to registrar training
  • provide dedicated supervisors and robust personal development plans
  • improve onboarding and appraisal systems

Independent and charitable providers

Role of independent and charitable organisations in training

• Independent and charitable providers already contribute significantly to NHS care and could expand training capacity
• Opportunities exist in tertiary referral settings, fellowships and specialist services (for example, paediatric palliative care, ophthalmology)
• Barriers include lack of formal recognition, funding and educational infrastructure (for example, portfolios, supervision roles)
• Collaboration with NHS trusts and Royal Colleges is essential to integrate training

Barriers and enablers

• Funding is a major constraint – training often occurs informally or during SPA time
• Consultant willingness and financial incentives are needed to support training delivery.
• Observation-only roles limit learning; a shift is needed to allow hands-on experience
• Positive models exist in other countries (for example, the USA, Canada) and in specialties like ophthalmology

Training innovations and opportunities

• Independent sector offers stable, efficient environments that are ideal for training
• Potential for high-volume, niche and specialist training (for example, anaesthesia, gastro hubs)
• Private patient units and resident medical officer roles could be leveraged for training
• Out-of-hours training and 360-degree learning could be built into rotations

Technology and future skills

• Independent sector is well-positioned to support AI initiatives and digital innovation
• There is a need to align UK training with global trends in tech-enabled healthcare

Training reform and integration

• Communication gaps discourage applicants from pursuing specialty training
• Indemnity and contract issues hinder participation in independent sector training
• Deanery relationships with private providers need reform and better resourcing
• Lead employer models could help streamline contracts and benefits

Retention and career progression

• Remuneration differences and indemnity costs affect retention and movement between sectors
• Certificate of Eligibility for Specialist Registration (CESR) route is under-supported; many trained doctors fall through the cracks
• Geographical flexibility and incentives are needed to retain doctors in less desirable areas

Community care and prevention

• Independent sector can support screening and community-based care due to its non-acute set-up
• ICBs and NHS England-funded posts show potential for collaborative preventative care training

Final reflections

• Local deaneries should engage with independent sector providers to create joint training opportunities
• Portfolio careers across sectors could become more common
• Despite offers from the independent sector, uptake by NHS trusts is low – this could be improved via postgraduate deans

Foundation doctors

Opportunities to explore specialties

• Taster days and career events (especially mid-FY1) are valuable for exploring different specialties
• Rotations help shape career decisions – some discover new interests or change paths
• Enhance programme is beneficial but inconsistently implemented and understood
• 80% of training time in FY2 was seen as helpful for development
• Preferencing FY2 posts during FY1 is valued by trainees, as it allows early planning and alignment with career goals. However, the lack of timely information and clarity about available posts can undermine its effectiveness
• Funded continuing professional development (CPD) opportunities like PgCerts are valued and should be retained

Misalignment between training and career goals

• Random allocation of rotations limits agency and alignment with personal goals
• Lack of structured teaching in some departments; training often secondary to service provision
• Unclear objectives across training stages – what should be learned in medical school versus foundation versus specialty?
• Disparities in exposure (for example, district versus urban hospitals) affect competitiveness for specialty posts
• Recruitment bottlenecks create stress, burnout and pressure to build portfolios in personal time

Service versus learning balance

• Foundation doctors often feel like service providers rather than learners
• Clinic and theatre time is limited; more hands-on experience is needed
• Staying in the same trust but rotating departments helps maintain support networks

Supervision and support

• Wide variation in supervision quality – some excellent, others lacking
• Internal-only job applications limit mobility for those wanting to move trusts
• Concerns that health service needs may increasingly outweigh trainee development

Systemic challenges

• Specialty job criteria do not always reflect what makes a good doctor
• Portfolio pressure starts early, even in undergraduate years
• Burnout is linked to the need for extracurricular effort to remain competitive

Suggestions and reflections

• Need for clearer objectives per rotation (for example, what to expect from 4 months in trauma and orthopaedics or paediatrics)
• Flexibility tools like swap shops are appreciated
• A rethink is needed about what a foundation doctor should be able to do by the end of the programme

Patients and public voice

Inadequate inclusion of patient voices in medical training

• Patient perspectives are often missing, especially in early academic stages
• Medical education focuses more on clinical knowledge than on lived experiences
• There is a need for structured opportunities to meaningfully engage with patients

Embedding patient voice in curriculum

• Patient involvement should be a core part of the curriculum, not a token gesture
• Emphasis on empathy, active listening and shared decision-making
• Initiatives like ‘double day’ show promise but need scaling

Cultural competence and bias awareness

• Doctors often lack preparation for diverse community settings
• Unconscious bias and lack of cultural humility can harm patient care
• Training must include cultural competence as a lived skill, not just theory

Moving from paternalism to partnership

• Shift needed from ‘doctor knows best’ to collaborative, trauma-informed care
• Emphasis on relational, not transactional, models of care
• Empathy and holistic thinking should be taught and modelled

Community-based training

• Doctors should be immersed in community settings through structured placements
• Understanding local contexts and working with community groups are vital
• Community-based rotations should be mandatory, not optional

Technology in care

• Digital tools offer benefits but also risk exclusion and fragmentation
• Doctors need training in digital literacy and when not to use tech
• Technology should enhance, not replace, relational care

Long-term health and prevention

• Training should focus on holistic, person-centred care
• Understanding social determinants of health is essential
• Doctors should collaborate with community organisations and empower patients in prevention

Structural and environmental change

• Training alone is not enough – workplace culture and leadership must support inclusive care
• Diverse workforce and patient-informed feedback are key to improvement

International medical graduates (IMGs)

Factors attracting IMGs to the UK

• Push factors: limited opportunities, economic issues, poor working conditions, personal goals and conflict in home countries
• Pull factors: high-quality training, better lifestyle, recognition of UK qualifications and English-speaking environment
• GMC registration: seen as relatively accessible
• NHS reputation: globally respected healthcare system

Recognition of previous experience

• Challenges:
  • difficulty documenting prior experience due to unfamiliarity with UK systems (for example, e-portfolio)
  • need for reflective skills and understanding of NHS operations
• Progress:
  • some specialties allow direct higher-level entry based on competencies
  • CREST form helps evidence foundation capabilities but is limited for higher training
• General practice: short training duration makes shortening it further for IMGs problematic

Integration into NHS teams

• Support needs:
  • 1-to-1 meetings, training welfare officers, enhanced induction and shadowing (4–6 weeks)
  • cultural safety training for supervisors
• Barriers:
  • perception that IMGs are difficult to support
  • lack of educational support for IMGs in LED posts
  • inadequate data tracking by trusts on IMG cohorts

Career development opportunities

• Issues:
  • limited access and awareness of opportunities
  • inequity in eligibility (for example, some roles only open to resident doctors)
• Recommendations:
  • establish IMG and portfolio support networks
  • promote diverse leadership and good mentorship
  • ensure transparency in recruitment
  • implement ‘welcoming and valuing international medical graduates’ programme effectively

Contribution to NHS evolution

• Strengths:
  • IMGs enhance diversity and resilience
  • many are interested in primary care, helping address GP shortages
  • bring holistic and resourceful approaches to care
• Needs:
  • better support and recognition
  • retention strategies to maintain their contribution, especially in underserved areas

GP100

Challenges in GP training

• Training instability: frequent relocations, long travel times and lack of job security disrupt life planning, continuity of training and trainee morale
• Limited clinical exposure: reduced patient-facing time and over-reliance on blended learning hinder real-world readiness
• Infrastructure deficits: inadequate clinical space, outdated premises and insufficient digital infrastructure limit training capacity
• Burnout and admin burden: both trainees and trainers face high workloads and insufficient administrative support
• Assessment overload: excessive and sometimes irrelevant assessments detract from practical learning
• Variability in training quality: inconsistent supervision and lack of standardisation across regions affect training outcomes
• Negative public perception: media portrayal and GP ‘bashing’ undermine morale and recruitment

Proposed improvements

• Extend training duration: a fourth or even fifth year could enhance clinical competence and allow for specialist interests
• Individualised and flexible training: tailor pathways to accommodate personal circumstances and career goals
• Business and leadership skills: integrate training on practice management, commissioning and leadership
• Post certificate of completion of training (CCT) support: formal mentoring, fellowships and clearer career pathways to ease transition into practice
• Curriculum reform: align content with real-world GP roles, reduce unnecessary content and focus on core competencies
• Enhanced supervision: improve support for trainers and ensure adequate supervision time and quality
• Digital and multidisciplinary training: prepare trainees for digital triage, AI integration and working in multidisciplinary teams (MDTs)
• Support for IMGs: acknowledge diverse backgrounds and provide tailored support for international graduates

System-level recommendations

• Investment in premises and infrastructure: expand and modernise facilities to accommodate more trainees
• Ringfenced funding: secure budgets for training, supervision and administrative support
• Faculty development: recruit and retain GP educators with adequate support and recognition
• Standardisation and quality assurance: ensure consistent training experiences and ongoing trainer evaluation
• Equity and inclusion: address health inequalities through targeted training and support for underserved areas
• Public engagement and image: promote general practice as a rewarding and respected career

Innovative ideas

• GP exchange programmes: allow trainees to experience different practice environments
• Reverse engineering the ideal GP: design training based on future needs and patient expectations
• Centric user design: involve patients in shaping training priorities
• Trailblazer and spin fellowships: support GPs in deprived areas and encourage portfolio careers
• Multi-learner models: use urgent care centres for hands-on training across disciplines

Public health

Effective training approaches

• Need for national standards: inconsistent training across regions; call for standardisation and quality monitoring
• Holistic skill sets: emphasis on communication, multidisciplinary teamwork and emerging areas like AI and genomics
• More NHS-specific placements needed to complement local authority experience
• Transition support: structured support for registrars moving into consultant roles is essential

Supervision and collaboration

• Funding gaps: lack of remuneration for educational supervisors limits capacity
• Diverse portfolio route: valuable but under-supported; needs clearer structure
• Supervisor accreditation: inconsistent across regions; opportunity for regional collaboration
• Continuity of supervision: valued in some regions; promotes better oversight and support
• Integration with other specialties: needed to embed public health principles across healthcare

Equitable recruitment challenges

• Medical versus non-medical backgrounds: each brings strengths; recruitment processes may favour medical applicants
• Virtual placements: being explored to widen access and cross-professional learning
• Differential attainment: persistent disparities, especially among BME and older candidates
• Academic pathways: often favour medical trainees; need to open up to non-medical candidates
• Geographical equity: trainees often placed far from preferred locations, affecting retention

Support systems for trainees

• Health protection placements: often too short; longer placements recommended
• Examination support: varies by region; needs standardisation
• Pastoral support: includes HR, surveys and reasonable adjustments
• Peer support: buddies and group placements help reduce isolation
• Career coaching: needed throughout training to prepare for consultant roles

Funding and resource allocation

• Educational supervisor payment: inconsistent and insufficient; affects training quality
• Joint training initiatives: with general practice to bridge NHS knowledge gaps
• Out-of-programme (OOP) opportunities: valuable but unevenly distributed
• Pay disparities: between medical and non-medical trainees; affect morale and equity

Shifting from treatment to prevention

• Curriculum review: opportunity to emphasise soft skills, leadership and capability-based progression
• Public health identity: needs strengthening to clarify its role in the broader system
• Community and public health placements: expansion needed beyond local authorities
• Early integration: embed public health in undergraduate and foundation medical training
• Visibility and advocacy: improve communication skills, media presence and public engagement

Newly qualified consultants and GPs

Transition from trainee to consultant

• Challenges: transition often a shock due to increased responsibility and reduced supervision
• Consultant life: offers more control and fewer night shifts but includes significant managerial and political responsibilities
• Training gaps: trainees often lack preparation for the realities of consultant roles, especially in leadership and autonomy

Career progression and opportunities

• Limited posts: high competition in specialties like sports and exercise medicine; many move to the private sector
• Anaesthesia: bottlenecks and workforce shortages; fellow posts are increasing but not ideal as a default route
• Career breaks: returning can be difficult due to rising competition

Training quality and patient care

• Positive aspects: consultant-heavy specialties like anaesthesia offer good exposure; rotations broaden experience
• Areas for improvement:
  • earlier autonomy in training
  • better understanding of consultant roles during training
  • more structured preparation for decision-making and leadership

Skills for future healthcare needs

• Missing skills: business planning, leadership, governance, quality improvement and NHS change management
• Leadership: should be a core part of training, not optional
• Primary–secondary care interface: more integration needed to maintain perspective and continuity

Preventative care and public health

• GP training: disease management shifting to nurses; GPs may lose key skills
• Anaesthesia: preventative care not well integrated
• Sports medicine: includes a 6-month public health placement, but impact is limited by duration

Innovations and training models

• Quality improvement hubs: offer leadership opportunities for residents
• US model: no rotational training, better work–life balance and continuity
• Simulation:
  • useful for routine tasks and international students
  • should be a learning tool, not used for recruitment
  • virtual reality: effective in GP training for immersive learning

Reflections and recommendations

• Burnout awareness: more focus needed on wellbeing and work–life balance
• Flexible training: many would have preferred less than full-time (LTFT) training for a smoother transition
• Mentorship: continuous, discreet mentorship vital for personal and professional development
• Realistic expectations: trainees need honest insights into the realities of NHS work

Resident doctors with neurodivergence (ND)

Challenges faced by doctors with ND

• Access to reasonable adjustments: often delayed, inconsistent and bureaucratic. Many doctors with ND face stress navigating multiple departments (HR, IT, OH)
• Bespoke support: needs to be tailored to individual conditions. Uniformity and equity across regions and specialties are lacking
• Knowledge gaps: employers and educators often lack understanding of ND needs. Inclusive conversations and universal design principles are underused
• Stigma and disclosure: fear of being labelled or misunderstood discourages disclosure. Many conceal their ND until overwhelmed
• Workplace environment: sensory overload, lack of quiet spaces and poor system design (for example, no breaks) exacerbate challenges
• Transitions: frequent rotations and system changes make it hard to maintain consistent support

Training and support gaps

• Training design: current systems reward conformity and rapid adaptation, disadvantaging doctors with ND
• Supervisor support: inconsistent and often inadequate. Supervisors need more time, training and CPD to support trainees with ND effectively
• Adjustment passports: useful but underused due to stigma and lack of awareness
• Peer support: valuable but not widely available. Role models and ND-positive environments are needed
• Career coaching: should be tailored to individual strengths and needs. More flexible pathways and early guidance are essential

Technology and tools

• Assistive tech: tools like text-to-speech, transcription and mind mapping are helpful but access is delayed or inconsistent
• Licensing issues: software often expires or is tied to specific machines, limiting portability
• AI and innovation: NHS lags in adopting modern tech that could ease workload for doctors with ND

Systemic and cultural barriers

• Bias and misunderstanding: ND traits are often misinterpreted as incompetence or laziness
• Assessment inconsistencies: different providers give varying diagnoses and recommendations. Need for standardisation
• Rigid structures: difficult to switch specialties or adapt training to individual needs
• Curriculum gaps: ND is not well integrated into medical education. Inclusion would reduce stigma and improve understanding

Recommendations and reflections

• Neuro-affirmative approach: recognise ND as a difference with strengths, not a deficit
• Inclusive curriculum: embed ND awareness in undergraduate and postgraduate training
• Early screening and support: should be done with proper career guidance and support structures
• Leadership and visibility: more senior ND role models needed to foster a culture of openness and support
• Patient care: doctors with ND often bring emotional fluency and empathy – skills vital for future healthcare

Royal College and faculty presidents

Structural and systemic barriers

• Training is deprioritised due to service pressures, financial constraints and workforce shortages
• Trainers lack protected time (SPA time often not honoured), limiting hands-on supervision
• Workforce planning is reactive, not aligned with long-term needs, especially in underserved areas
• Inconsistent definitions of full-time work across regions create confusion and inequity

Supervision and mentorship

• Imbalance in supervision: over-supervised during the day, under-supervised at night
• Supervision should be seen as investment, not a cost – key to recruitment and retention
• Lack of structured mentorship: trainees need support beyond clinical skills (for example, research, leadership)

Training environment and exposure

• Limited exposure to complex cases; current models focus on low-acuity care
• Training should reflect modern healthcare, including community-based and multidisciplinary care
• Mismatch between training locations and workforce needs – training is concentrated in large hospitals
• Support for regional training exists but requires planning to avoid overburdening services
• Continuity versus curriculum coverage: reduce rotations while ensuring diverse clinical exposure

Innovation, technology and future skills

• Trainees are eager to engage with innovation but need guidance and opportunities
• Simulation, AI and digital literacy should be core components of training
• Internships in tech and innovation could foster readiness and improvement culture

Policy, funding and incentives

• Funding is opaque and fragmented, undermining trust and planning
• Shift from target-driven to incentive-based recognition (for example, re-imagining clinical excellence awards)
• Educators need recognition through financial incentives, career progression and institutional support

Additional considerations

• Consider competency-based progression over rigid task hierarchies
• Explore placements beyond traditional specialties, including community and private sectors
• Questions raised about training adequacy, integration of new technologies and prevention in care

Resident doctors with disabilities

Key challenges for resident doctors with disabilities

• Access to reasonable adjustments:
  • difficult, delayed and inconsistent across regions
  • lack of national guidance and standardised protocols
  • doctors must often self-advocate and repeatedly justify their needs
  • financial burden and poor procurement processes exacerbate issues
• Discrimination and stigma:
  • bias in recruitment, training and workplace culture
  • fear of disclosure due to potential career repercussions
  • disabled doctors often feel excluded or misunderstood by peers and supervisors
• Rigid training structures:
  • inflexible systems, rotations and assessments
  • examinations and recruitment processes not adapted for individual needs
  • lack of co-ordination between training bodies and employers

Support and disclosure

• Disclosure barriers:
  • power dynamics and fear of negative consequences
  • lack of trained, compassionate supervisors
  • need for clear, safe pathways for disclosure
• Health passports:
  • suggested as a transferable tool for consistent reasonable adjustments across roles and regions
• Professional support:
  • inconsistent access to occupational health and professional support units
  • no designated disability advocates in many settings

Flexible training and less than full-time (LTFT)

• Access and perception:
  • LTFT often treated as a workaround rather than a right
  • concerns about masking systemic issues
  • more accessible in non-shift based specialties
• Rotations and specialty access:
  • geographical constraints not considered in placements
  • lack of tailored career support and specialty-specific guidance

Examination and recruitment barriers

• Assessment issues:
  • examination formats disadvantage ND and disabled doctors
  • repeated reapplication for reasonable adjustments is burdensome
  • fear of requesting adjustments during interviews
• Recruitment rigidity:
  • group 2 applicants (those with disabilities) face repeated justifications
  • need for direct hospital applications and alternative pathways

Systemic recommendations

• Reasonable adjustments:
  • proactive, standardised reasonable adjustment processes from induction
  • central funding and HR passporting across rotations
• Awareness and education:
  • mandatory training on disability and inclusion for all doctors and supervisors
  • promote lived experience as a strength
• Financial equity:
  • address financial disadvantages of LTFT and self-funded adjustments
• Training structure reform:
  • flexibility in training pace and location
  • consider CESR-style portfolio pathways and longer placements

Inclusive innovations

• Simulation and digital learning:
  • immersive modules to raise awareness of disabled doctors’ experiences
  • e-learning on workplace accommodations and lived experiences
• Mentorship:
  • pairing disabled trainees with supportive supervisors
  • role models and peer support networks are vital

Final reflections

• Cultural change needed:
  • attitudinal shifts are harder than policy changes
  • quick wins are possible, but long-term equity requires systemic reform and inclusive leadership

Less than full-time and flexibility

LTFT training – experiences and barriers

• Positive aspects:
  • LTFT is widely valued for personal wellbeing and work–life balance
  • application processes have improved (for example, digital forms like MS Forms)
  • some regions offer clear guidance and streamlined systems
• Challenges:
  • information gaps: unclear impact on pay, CCT dates, leave entitlements
  • cultural resistance: persistent stigma in some specialties and regions
  • inconsistency: regional variation in processes and approval timelines
  • delays: 16-week wait for implementation, even in urgent cases
  • slot sharing: helps with flexibility but complicates rota planning
  • admin burden: multiple approvals, overwhelmed admin teams
  • trust constraints: service pressures limit flexibility

Impact on career progression

• Positive: some LTFT doctors access fellowships and development roles.
• Negative:
  • inequity in access to opportunities
  • teaching often scheduled on non-working days
  • persistent underpayment and admin errors
  • short rotations hinder team integration and continuity

Terminology – is ‘LTFT’ the right term?

• Poll result: 63% prefer ‘flexible working’ over ‘LTFT’
• Criticisms:
  • misleading term – 80% of a 48-hour rota is still full-time by most standards
  • contributes to negative public and media perceptions
• Suggestions:
  • rebrand to reflect actual working patterns
  • align definitions across specialties and with public understanding

Out of programme (OOP) – experiences and flexibility

• Positive aspects
  • valuable for fellowships, education and personal development
  • supportive training programme directors (TPDs) and clear processes in some regions
• Challenges:
  • recognition: clinical work during OOP often not counted towards CCT/ARCP
  • admin issues: email deactivation, outdated records, lack of feedback
  • dual employment: especially in research OOPs
  • regional variation: inconsistent processes and support

Suggestions for improving OOP

• Simplify categories: some support for a single OOP category; others prefer distinctions (for example, OOPR, OOPT)
• Recognition: count relevant clinical and leadership work towards training
• Standardisation: consistent processes across regions
• Support:
  • regular check-ins during OOP
  • access to study budgets and support funds
  • clear Annual Review of Competency Progression (ARCP) timing and visa support

Broader recommendations

• Operational improvements: streamline entry to and exit from training
• Equity: ensure fair access to LTFT and OOP across all specialties and regions
• Terminology and culture: shift language and attitudes to reflect modern, flexible training needs

Medical schools

Preparation for postgraduate training

• Lack of data on how well students are prepared as FY1s due to geographical dispersion
• Strong support structures in undergraduate training are not mirrored in postgraduate settings
• Final year assistantships help, but focus has shifted to examinations (for example, Applied Knowledge Test (AKT)), reducing engagement with soft skills
• Students feel disempowered by inconsistent postgraduate training pathways and changing requirements
• Suggestion to treat undergraduate and foundation training as a single continuum
• Integrated training posts in secondary care could offer continuity of training, broaden skills and provide geographical stability
• Concerns about the foundation matching scheme and its impact on support and continuity

Transition to community-based care

• Limited capacity and infrastructure in community placements
• Community services are vulnerable to funding cuts and reconfiguration
• Competition for placements from other healthcare professions
• Negotiating with multiple small providers is complex and inconsistent
• Palliative care offers a successful model due to its unique funding and structure
• National collaboration could help address shared challenges in capacity and funding

Emphasising preventive care

• Partnerships with local authorities are administratively burdensome because they are external to the NHS
• Preventive care initiatives exist (for example, refugee health, alcohol services), but student engagement is mixed
• Innovative placements are difficult to establish and scale
• New modules (for example, ‘lifestyle medicine and prevention’) aim to build personal and population-level health awareness

Integrating technological advancements

• Enthusiasm for data science exists, but implementation varies and requires trade-offs in curriculum content
• Student-led tech projects show promise but are limited in scale
• Funding constraints necessitate use of internal university resources
• Students underuse available systems like electronic health records
• Prescribing training is hindered by lack of access to real prescribing systems pre-qualification
• Need for better accountability and transparency in use of training tariffs

Career pathway guidance

• Students are seeking career advice earlier due to awareness of bottlenecks
• Career decisions often influenced by clinical placements and informal discussions
• Medical schools struggle to balance strengthening applications versus broad exposure
• Career support includes portfolio development and early awareness of selection criteria
• Some schools now include non-clinical career options in career days
• Signposting to external professional bodies is recommended due to limited internal capacity

Final reflections

• Without accountability for how training tariff funds are spent, systemic improvements will remain limited

Craft specialties

Challenges in current training

• Anaesthetics: curriculum is appropriate, but there is a shortage of trainees and training capacity. Service provision detracts from training
• Cardiology: dual accreditation with general medicine is burdensome. Curriculum needs a rewrite. Service demands dilute training
• Radiology: consultant shortfall and reluctance to sign off competencies delays progression
• Surgery: loss of training opportunities due to independent hubs. Service provision outweighs training
• Obstetrics and gynaecology: mismatch in trainee interests versus population needs. Need for more advanced surgical training
• Gastroenterology: high service commitment limits specialty training. Imminent workforce crisis due to retirements
• Neurosurgery: oversubscription and subspecialisation limit general skills and job prospects

Overarching issues

• Many trainees are not job-ready post-CCT; post-CCT fellowships are often needed
• Reduced access to training cases due to independent sector use
• Concerns over whether training funds (PGDME tariff) are being used effectively
• Need for long-term (15-year) workforce planning, independent of political cycles
• Suggestion: every list should be a training list; everyone should be both trainer and trainee

Geographical and institutional mismatches

• Training posts not aligned with procedural capacity (for example, anaesthetics)
• Rural areas lack specialist services and struggle to retain trainees
• Use hub-and-spoke model (for example, cardiology) and allow secondments to high-volume centres
• Curricula can block training in some areas due to lack of opportunities

Integration of new technologies

• Barriers: funding, IT infrastructure, lack of academic capacity
• Radiology: AI use increasing, but access to training lists is limited
• Surgery: robotics not well integrated into curricula; digital literacy needed
• Gastroenterology: basic training still lacking, let alone advanced tech
• Obstetrics and gynaecology: robotics relevant to a small percentage; better suited for post-CCT
• Radiotherapy: AI being used; integration into curricula under consideration
• Suggestion: differentiate between tech for service delivery, training and treatment

Multidisciplinary and early intervention

• Loss of ‘firm’ structure reduces MDT exposure
• Trainees need more access to MDT meetings early in training
• Radiology and surgery could contribute more to early intervention with better training access
• Suggestion: reduce admin, increase theatre time, support research

Improving procedural training

• Emphasise immersive and simulation-based training (for example, boot camps)
• Reduce admin burden on trainees and trainers
• Reform training tariff: link funding to training quality and transparency
• Establish national simulation centres and ensure equitable access
• Improve core training to better prepare for higher specialty training

Clinical stakeholders

Postgraduate medical training is being evaluated for its effectiveness in preparing doctors to work in MDTs alongside other healthcare professionals such as nurses, pharmacists and dentists. The focus is on enhancing interprofessional collaboration, supervision and training to improve patient safety and healthcare delivery across diverse settings.

• MDT preparation. Current postgraduate medical training needs improvement to better prepare doctors for effective collaboration with nurses, allied health professionals, pharmacists, midwives and healthcare scientists, emphasising reciprocal supervision and breaking down professional hierarchies
• Cross-professional supervision. There is a need for supervision models that cut across professions, focusing on supervisory skills rather than roles, despite the lack of a unified definition of supervision across healthcare disciplines
• Examples of effective MDT training. Programmes like maternity skills and drills training demonstrate benefits of joint learning for patient safety and role understanding within teams
• Dentistry integration challenges. Dentists are siloed from doctors despite shared undergraduate training; dentistry requires one-to-one supervision due to its surgical nature and would benefit from access to patient records to enhance training and care
• Digital skills and tools. Trainees need early exposure to electronic patient record systems and digital tools to adapt swiftly to technological changes in healthcare
• Leadership and resource allocation. National and regional leadership should support joined-up training by allocating resources proportionately, promoting multiprofessional placements and modernising regulatory standards to reflect current competency needs
• Cultural and structural changes. To normalise MDTs and interprofessional training, organisational accountability is essential, as is redefining professional roles based on shared skills rather than differences
• Adapting training for healthcare shifts. Training must evolve to prepare doctors for community-based care, digital transformation and prevention-focused models, emphasising experiential learning and modularised competencies aligned with practice needs
• Defining medical uniqueness. Clarifying the unique contributions of medical professionals is vital as roles change, ensuring doctors focus on tasks requiring their expertise while collaborating effectively with other healthcare workers

Think tanks

Efficiency and return on investment in the training pipeline

A key theme was inefficiency within the doctor training pipeline. Concerns were raised about high cost of training nearly 80,000 doctors while failing to adequately transition them into the roles needed. The discussion stressed that addressing the ‘leakiness’ in this pipeline is critical to enhancing the return on investment.

Financial burden of medical training

There was significant focus on the financial challenges faced by doctors in training. High examination fees and other expenses, compounded by additional responsibilities such as housing and family commitments, create a heavy financial burden. The conversation explored the balance between state-funded and self-funded expenses, with suggestions that state support for key costs could markedly improve the training experience.

Challenges in securing training placements

Another central concern was the increasing difficulty in finding available training placements.

With the growth in medical school places leading to more graduates, the system is experiencing pronounced bottlenecks. It was noted that any long-term workforce plan – including proposals to double medical school places – needs to be matched with an innovative training model that can accommodate the surge in trainees.

Bottlenecks and alternative career pathways

The discussion also examined the hurdles encountered in accessing official training posts. In response to these bottlenecks, there has been an observable rise in non-training LED roles, often filled by IMGs. This shift highlights the need for strategies that better balance the pipeline while ensuring that all roles contribute effectively to the workforce.

Flexibility and recognition in training

The need for flexibility in training was another important theme. Considerable discussion about acknowledging training and experience gained in non-traditional roles (such as LED posts) and creating more adaptable training pathways that respect varied career trajectories.

Understanding the dynamics of non-training roles

A call was made for better data collection to understand the characteristics and career trajectories of doctors in locally employed positions. Gaining deeper insights into this group is seen as vital for designing policies and training programmes that support their professional growth.

Workforce planning and salary influences

Issues related to salary subsidies for training posts and their impact on workforce planning were also raised. The possibility of trusts funding more training posts locally was discussed as part of a broader debate on finding the right balance between centralised control and local flexibility.

Clinical leadership and technological integration

Clinical leadership training emerged as a critical area, with emphasis on early preparation and a structured approach to developing these skills. At the same time, the integration of new medical technologies, including digital skills and AI, into postgraduate curricula was highlighted. The challenge lies in striking the right balance between leveraging technology and maintaining the human touch essential to patient care.

Industrial relations and transparency

Finally, industrial relations – particularly issues around pay and employment perceptions – were acknowledged as influencing trainee satisfaction and system transparency. Better data on the availability of training posts and applicant numbers was seen as essential to empower trainees and inform effective career planning.

Richmond Group charities

Challenges faced by patients in interacting with doctors and the NHS

• Misdiagnosis and referral issues: especially in neurology and musculoskeletal (MSK) conditions; need for more confident and accurate consultations
• Lack of holistic care: doctors often overlook mental health, co-morbidities and community-based care options like hospital-at-home or frailty services
• Poor communication: rushed consultations, clinical jargon and lack of empathy lead to patients feeling unheard or unsupported
• Insufficient knowledge: gaps in understanding long-term conditions, frailty and mental health, especially in emergency settings

Improving postgraduate training for complex and long-term conditions

• Workforce data: better data collection to inform training needs and workforce planning
• Condition-specific training: more focus on MSK, menopause-related conditions, frailty and multimorbidity
• Multidisciplinary learning: training alongside other professionals like physiotherapists and occupational therapists
• Community exposure: more placements in community settings to understand care outside hospitals
• Digital literacy: training in digital tools and remote monitoring (for example, for Parkinson’s)
• Workforce readiness: preparing for future care models and technologies

Understanding social, cultural and economic contexts

• Personalised care: doctors need to better understand patients’ lived environments, including home set ups and carer support
• Cultural competence: especially in areas like pain management where cultural differences affect patient experience
• Assumptions in discharge planning: overlooking social factors like housing or family support can lead to poor outcomes

Role of charities in medical training

• Patient-led teaching: involving patients in training to share lived experiences
• Placements and mentorship: charities can offer community-based learning and mentorship, especially for underrepresented groups
• Clinical research: promoting research careers, particularly in mental health
• Multidisciplinary teams: charities should be integrated in care pathways and training
• Shared decision-making: charities can help train doctors in collaborative care approaches

Key recommendations for change

• Training post distribution: align training locations and specialties with population health needs
• Capability frameworks: embed these in all professional standards to ensure consistent, high-quality care
• Shared decision-making: make this a core part of training
• Communication and personalisation: improve training in empathetic communication and personalised care
• Interprofessional collaboration: systematically embed teamwork and patient-centred care across all PGME

Clinical academics

What is working well

• Integrated academic pathways (for example, ACF, ACL, AFP) are valued for their structure, flexibility and support
• NIHR funding and university affiliations provide strong mentorship and research opportunities
• Flexibility in entry points and career progression is appreciated
• Gender balance has improved at senior levels due to supportive mechanisms
• Geographical stability and localised PhD opportunities are seen as strengths

Key challenges

• Time constraints: clinical workload limits research engagement, particularly for trainees outside the NIHR Integrated Academic Training (IAT) Programme
• Post-PhD bottlenecks: lack of clinical academic posts after CCT leads to attrition
• Funding and pay: academic careers are less financially attractive and secure
• Mentorship gaps: inconsistent access to mentors, especially outside teaching hospitals
• Cultural barriers: academic roles are undervalued in some clinical settings
• Equity issues: disparities in access to research opportunities for SAS doctors and LEDs, women and ethnic minorities

Barriers for non-IAT and SAS doctors and LEDs

• Structural exclusion: limited pathways and recognition for non-training doctors
• Stigma: perception of being ‘less than’ among peers
• Lack of protected time: no formal time allocated for research or teaching
• Mentorship deficit: few mentors available in smaller or non-academic hospitals

Expanding opportunities beyond teaching hospitals

• Hub-and-spoke models: link academic centres with smaller hospitals
• Digital supervision: use remote tools to support rural and underserved areas
• Redistribution of posts: allocate academic roles based on population need
• Grassroots training: embed research skills early in medical education

Gender disparity and equality, diversity and inclusion (EDI)

• Maternity and parental leave: need for better support and clearer policies
• Career progression: delays due to PhDs and caring responsibilities
• Pay inequities: inconsistent access to academic pay supplements
• Representation: underrepresentation of BME groups in leadership and funding panels
• Support measures:
  • returner schemes
  • protected academic time
  • mentorship and role models
  • localised EDI support

Suggestions for improvement

• Increase academic training capacity by converting standard posts
• Create flexible fellowships and non-IAT pathways
• Encourage routine data use for research and audits
• Promote early exposure to research in medical school
• Ensure academic job availability post training

Inclusive PGME practice

Systemic and structural barriers

• Rotational training disrupts support networks, especially for trainees with protected characteristics
• Direct discrimination and prejudice persist, with fear of raising concerns due to potential career repercussions
• Cultural misunderstandings affect IMGs, especially around communication and hierarchy
• Workplace integration for IMGs is lacking; cultural awareness should be part of induction
• Intersectionality and socioeconomic background impact on career progression and are often overlooked

Work–life balance and flexibility

• Geographical inflexibility and lack of support for child care hinder career progression
• Parental leave uptake is low, especially among fathers; shared parental leave is underused
• Occupational benefits (for example, maternity leave, sick pay) are inconsistent across contract types and transfers

Differential attainment and recruitment

• UK graduates from ethnic minorities face significant attainment gaps (for example, 12% lower examination scores)
• IMG-focused interventions may overlook UK ethnic minority graduates
• Recruitment processes (for example, point scoring) disadvantage those unable to afford unpaid opportunities
• LEDs lack access to training, supervision and career development

Disclosure and support

• Unconscious bias and lack of supervisor training hinder safe disclosure
• Fear of being labelled or ignored discourages reporting of discrimination
• Supervisors need training in cultural competence, intersectionality and differential attainment

Equity in training opportunities

• Cultural change is needed beyond policy – systems must be visible and trusted
• Regular audits and regulatory oversight are essential to ensure equity
• LED posts should be recognised for training; ST7s could take dual roles to prepare for consultancy

Inclusive learning approaches

• Simulation training can address discriminatory behaviours and improve cultural competence
• Digital learning and alternative placements can support inclusion but must avoid creating a two-tier system
• Mandatory EDI training is needed, led by engaged and knowledgeable trainers

Recommended systemic changes

• Supervisor training on EDI, unconscious bias and intersectionality
• Improved communication of EDI initiatives and changes
• Better occupational benefits, especially for parental leave
• Appoint senior EDI advocates in each deanery to support trainees

Dental

Valuable aspects of current training

• Oral and maxillofacial surgery (OMFS) training: offers dual qualification benefits, hospital exposure and development of non-clinical skills (for example, stress management, prioritisation)
• Multi-year, structured training with defined outcomes supports equitable preparation for dental core training (DCT)
• Specialty exposure: rotations across oral medicine, radiology, paediatrics, etc increase engagement and recruitment into smaller specialties
• Simulation and feedback: simulation-based training and regular feedback are especially helpful for those returning from leave or training LTFT

Challenges and recommendations

• Lack of standardisation: inconsistent DCT experiences, especially in OMFS, with some trainees facing unsafe workloads and poor supervision
• Over emphasis on service provision in OMFS posts undermines educational value
• DCT3 posts: limited availability creates barriers to specialty training; some posts withdrawn post-interview
• Run-through posts: favoured for continuity/stability; reduce stress from frequent relocations
• LTFT working: poorly supported and stigmatised, especially for carers, women and disabled trainees

Cultural and systemic barriers

• Stigma and bias: cultural issues in training environments, including assumptions about competence and resistance to flexible working
• Funding transparency: training funds often not visible or accessible at unit level
• Educational supervision: removal of professional activity (PA) time for educational supervision and lack of protected time for registered clinical professionals discourage participation

Workforce and recruitment

• OMFS DCT posts remain unfilled, increasing pressure on existing trainees
• National recruitment: improved fairness and diversity but can result in poor trainee–unit matches. Regional flexibility suggested
• Retention: longer, structured training (for example, 4-year paediatric dentistry) increases likelihood of trainees staying in region

Digital and community-based care

• Digital training gaps: especially in orthodontics – lack of hands-on experience with scanners, aligners and remote tools
• Community care readiness: current training does not adequately prepare dentists for community-based roles, leading to over-referral
• Remote supervision: being used to expand training in underserved areas, but infrastructure and trainer availability are limiting factors

Suggested reforms

• Training tariff for dental posts: to ensure trusts are resourced and incentivised to support dental training
• Curriculum reform: align training with digital and community care needs
• Return-to-training: tailored support for those returning from leave or with additional needs
• Cultural shift: promote wellbeing, work–life balance and inclusivity in training environments
• Primary care training: enable training in primary care settings using experienced specialists, but address tariff funding barriers

4 nations

Top priorities for redesigning postgraduate medical training

• Generalist-first approach: training should begin with generalist skills based on population health needs, followed by specialisation
• Human-centred training: shift from bureaucratic systems to personalised, supportive environments that foster belonging
• Alignment with service needs: training must reflect real-world service demands and workforce planning, not just trainee preferences

Systemic challenges

• Over complexity: training has become bureaucratic and inflexible
• ARCP burden: reviews are overly labour intensive; AI could streamline them
• Rotational strain: frequent relocations disrupt continuity and wellbeing
• Retention issues: trainees are leaving due to systemic and environmental pressures
• Mismatch: training structures do not align with delivery models or future service needs

Workforce strategy and planning

• Need for integration: training must be embedded in broader workforce and service planning
• Instead of creating new roles, adapt existing ones to be more flexible and tech ready
• Generalism versus specialism: balance is needed – generalist roles are essential but not universally applicable

Training in underserved areas

• Embed training in community settings to reflect real patient needs
• Infrastructure gaps: rural and remote areas lack continuity of care and training alignment

Curriculum reform and collaboration

• Curriculum development: Royal Colleges may not be best placed to lead; statutory bodies could better align curricula with workforce needs
• Late oversight: curriculum oversight often comes too late to influence meaningful change
• Cross-nation collaboration: stronger, earlier collaboration across the 4 nations is needed to ensure consistency and quality

Transition from medical school to practice

• Problematic phase: transition to FY1 is the most stressful and burnout prone
• Integration needed: embedding foundation elements into medical school could ease the transition and manage oversubscription

Adapting to community-based and virtual care

• Virtual training: Scotland is leading in virtual clinics and VR-based communication training
• Flexibility: virtual models reduce relocation needs and expand access
• Human connection: despite tech advances, emotional intelligence and real-world problem-solving remain central

Leadership, digital health and population management

• Financial disincentives and structural issues deter clinicians from leadership roles
• Early exposure needed: leadership, innovation and digital skills should be introduced earlier in training
• Curriculum disconnect: generic skills like leadership are undervalued and poorly integrated
• Digital integration: technology should support, not replace, clinicians – clear communication is essential to reduce anxiety

Trust chief executives and chief operating officers

Balancing clinical and educational roles

The challenge of balancing clinical responsibilities with educational commitments was consistently highlighted. There is a growing tension between efforts to reduce clinical hours and the increasing demand for clinicians to take on supervisory and educational roles. While financial incentives were generally viewed as less effective than providing protected time or structural support, time constraints – particularly the lack of dedicated time for educational activity – were identified as a significant barrier to participation.

National clinical leadership programmes

The loss of national clinical leadership programmes was noted as a demotivating factor for staff taking on additional roles. Reintroducing access to such programmes was suggested as a potential non-financial incentive.

Job planning and educational supervision

A proposal was made to incorporate educational supervision in job planning by adjusting session tariffs to reflect the educational aspects of clinical work. This approach aims to integrate service and educational duties rather than adding extra responsibilities.

Impact of training expansion on service delivery

Concerns were raised about the disparity in service contributions between senior and junior trainees (F1s and F2s). While senior trainees contribute more significantly, it was emphasised that expanding training places must be carefully managed to avoid overburdening the system.

Workforce planning and financial constraints

The impact of financial pressures on long-term workforce planning was discussed, with immediate budget constraints often taking precedence over strategic considerations. Some roles have been reduced due to financial justifications.

Quality and productivity of registered doctors

Concerns were expressed about the quality and productivity of registered doctors in the post-Covid context, including increased sickness rates and challenges in integrating them into the service model. A balance between training and service delivery was seen as essential.

Reconfiguration and training opportunities

Hospital reconfigurations were noted to have implications for training. The importance of involving trainees and educational bodies in the process was emphasised, along with the potential for more varied training placements within group structures.

Enhancing the FY1 role

Suggestions were made to enhance the FY1 role by introducing more hands-on experience earlier in training, similar to the pathways for physician associates and advanced care practitioners. It was noted that FY1s currently contribute less to service provision than these roles.

Generational and contractual changes

The influence of generational shifts and contractual regulations on registered doctors’ training and work ethic was discussed. Current contracts were seen as potentially limiting the depth of learning and commitment compared to those for previous generations.

Generalist skills and training

The importance of generalist skills in medical education was emphasised, with concerns expressed that the current focus on super-specialisation may not align with the needs of most patients. Broader training was advocated to prepare doctors for managing a wide range of conditions.

Publication reference: PRN01835