Specialty training squeeze

‘Many foundation year 2 doctors are in a tough situation and fear they will be unemployed come this August.’

It might sound like a bold statement from F2 Luke Craddock but he is not alone in feeling that the lack of places on specialty training programmes represents a petrifying cliff edge so early in a medical career.

Forums and social media threads are full with worried resident doctors who say ‘everything feels so stacked against me’, that there is ‘no incentive for staying in the UK’ or that they are ‘genuinely shitting myself about being unemployed’.

The difficulty in securing a training place is laid bare in competition ratios that have soared in recent years.

In 2024, 59,698 applications were made for the 12,743 specialty training posts available at core trainee 1, specialty trainee 1, ST3 and ST4, a 39.5 per cent increase from the 42,794 applications made in 2023. This represents 4.7 applications made to every available post in 2024 compared with 3.4 per post in 2023, and 1.9 in 2019.

The number of unique applicants in 2024 was 25,496, confirmed by NHS England in response to a freedom of information request, showing that many doctors are applying for multiple posts. This means the ratio of unique applicants to total available posts is 2:1. The number of unique applicants rose to 33,108 in 2025; the total number of 2025 posts is yet to be confirmed.

The three specialties with the highest number of posts, general practice, internal medicine and core surgical training, were all over-subscribed in 2024 at 2.67:1, 3.69:1 and 5.25:1 respectively.

And competition ratios for popular programmes are eye watering. For ST1 level cardiothoracic surgery, community sexual and reproductive health, and public health medicine, competition was 45:1, 26:1, and 17:1 respectively.

Only one specialty, genitourinary medicine, had a competition ratio below one, at 0.53:1.

Specialty training places have been oversubscribed since publicly available records began in 2013, but never at such high levels. Ten years ago, the competition for general practice was 1.62:1, internal medicine 2.09:1 and core surgical training 2.19:1.

And COVID didn’t help matters. Disruption to the process due to the pressures of the pandemic led to ‘significant concerns’ from the BMA about a system with more exams, unverified self-scoring and a lack of interviews.

Dr Craddock, a regional representative of the BMA resident doctors committee, says the current situation feels ‘disparaging and depressing’ for his cohort, many of whom have graduated medical school with sky-high debts and receive real-terms pay still way below what it was 10 years ago despite gains made through the BMA’s pay restoration campaign.

When he spoke to The Doctor, he had applied for three specialties and said he decided against applying for some that he was interested in owing to the competition. Planning his applications and building his portfolio has eaten up ‘the majority’ of his annual leave and ‘a large amount’ of his free time.

Applications for specialties can be made either through self-assessment scores and interviews or through the MSRA (multi-specialty recruitment assessment). Dr Craddock says the rising competition for specialties has led to higher cut-off self-assessment scores. ‘This results in successful shortlisting being increasingly difficult to obtain for those at the beginning of their medical career,’ he says, noting how it takes time to build a portfolio.

Data shows an increasing number of doctors delaying entering specialty training after completing F2, and for longer periods of time. While some are having career breaks, others are taking LED (locally employed doctor) roles to build their portfolios. Of the 2020/21 F2 cohort, 70 per cent did not immediately proceed into specialty training, compared with 38 per cent of the 2012/13 cohort.

The GMC’s 2024 workforce report shows a growing number of doctors who had completed F2 but not entered core or specialty training – with 11,757 such doctors in 2023. The report suggests that to help retain these doctors, professional development pathways should be adapted ‘to account for skills and experience developed in LED roles’.

Dr Craddock says the ‘drastic state’ of the locum market and competition for LED jobs means many of his peers are looking for work opportunities overseas, or outside medicine altogether.

And he warns that the expansion of UK medical school places will only exacerbate competition in future years, forcing more UK-trained doctors to seek alternative work if training bottlenecks are not addressed. ‘At the current rate of applicant growth, specialty training posts would need to be increased by a staggering rate that I do not believe is feasible in the current climate,’ he says.

The upshot to all this competition is that more specialty training places are needed, so that all doctors feel like they have a pathway to progression within the NHS.

RDC has condemned the ‘persistent failure of UK and devolved nation governments’ in ensuring that the number of specialty training posts had kept pace with the UK’s need for an ever-larger medical workforce.

A motion endorsed by RDC members on 4 March called for a ‘multi-pronged approach’ to tackling the shortage of training places.

It means the committee will lobby for an increase to the overall number of training places, and also lobby for priority for access to existing posts to be given to graduates from UK medical schools. This comes with the caveat that IMGs (international medical graduates) registered and practising in the UK on or before 5 March 2025 have equal access to training places.

Increasing specialty training places would likely require hugely increased budgets and, crucially, enough senior doctors to train the next generation of specialists.

Partha Kar, a diabetes and endocrinology consultant, says there has been a ‘cycle’ of bottlenecks over the years with similar ‘ridiculous’ competition in the late 1990s and early 2000s.

He also fears ‘hundreds of doctors will be out of jobs’ by August if no solution is found, which he says would be ‘an absolute disaster’.

The situation now, he says, is a result of ‘disastrously poor workforce planning’ by NHS England and the GMC. ‘They have not got their maths right and now it’s arrived like a storm,’ he says.

Prof Kar says attempts to reduce the locum bill by ‘flooding the market with doctors on lower rates’ led to many IMGs working in the NHS, which still offered better rates than their home countries.

But he believes that strategy is at odds with ambitions in NHS England’s Long Term Workforce Plan, published in June 2023, to increase the domestic supply of doctors.

‘Once you are in the system, you will apply for the specialty posts,’ says Prof Kar, an IMG from India. ‘So trying to do the two things at once has caught them [NHS England] on the hop, and now it’s all come to a head.’

He is referring to criticism of the RDC policy position from some IMG doctors working in the NHS.

Mohit Bhagia, a resident doctor and IMG from India, says he understands the ‘concern is real’ among UK graduate doctors. But he argues UK graduates and IMGs are ‘grappling with a system that’s failing them’ with ‘training bottlenecks choking career progression’ for everyone.

He believes focusing on prioritising UK graduates is ‘turning doctors against each other’ and, for many IMGs, ‘feels like a slap in the face after years of keeping the NHS afloat’.

The Government’s migration advisory committee added all doctors to its shortage occupation list in 2019, meaning international doctors can apply for UK medical training on the same terms as UK graduates and are exempt from the resident labour market test. The move, aimed at addressing the shortage of doctors, was widely supported among the profession at the time.

According to the GMC, non-UK graduates make up 41 per cent of the medical workforce, up from 33 per cent in 2017. Its latest workforce report says that, in 2023, ‘the steady growth in the proportion of non-UK graduate doctors in training continued’, reaching 27 per cent of all doctors in training, up from 18 per cent in 2019.

The unique number of IMGs applying to specialty training doubled between 2023 and 2025 (from 10,402 to 20,803), whereas the number of UK medical graduates increased by 33 per cent (9,283 to 12,305). But, in 2023, UK graduates were offered 59 per cent of training posts, versus 41 per cent for IMGs – equal to their proportion in the workforce at the time.

The proportion of IMGs on training programmes depends on the specialty. In 2022, in England, IMGs made up less than 5 per cent of doctors on specialty training programmes where the competition ratio was greater than 5:1, the GMC notes in its 2023 workforce report. 

Programmes with ratios below 2.5:1, however, tended to have higher proportions of IMGs – except internal medicine. BMA analysis of 2023 data shows a similar trend, with traditionally less popular specialties being applied to by higher proportions of IMGs. This was the case in general practice (56 per cent) and core psychiatry (47 per cent).

A higher proportion of UK medical graduates are deemed ‘appointable’ applicants – that being, they meet specialty programmes’ individual threshold to be accepted following the self-assessment and interview process. In 2023, 37 per cent of all applicants were UK graduates, but they made up 51 per cent of appointable applicants.

And, for the two specialties with the highest number of IMG applicants, general practice ST1 and core psychiatry CT1, there are low offer acceptance rates among UK graduates – 55 and 52 per cent respectively, against a 69 per cent average acceptance rate among UK graduates. IMGs have an average 71 per cent acceptance rate.

Dr Bhagia, a regional representative of the RDC, says IMGs applying from overseas are already at a disadvantage, ‘simply because of their lack of systemic know-how’, such as of NHS pathways and application criteria.

He says that the squeeze on training places is a broader issue than the narrative of IMGs ‘taking places’ of UK graduates – and is contributed to by ‘dwindling junior-level resident doctor job opportunities, funding shortages, and mid-level scope creep’ as well as a ‘drying-up’ of long-term locum opportunities.

‘Add to this stagnated training numbers, an increasing number of UK medical school places, and foundation year doctors from previous cohorts who still have not secured training, and the scale of the problem becomes clear,’ he says.

Competition ratios taken alone can be an ‘inadequate metric’ to judge the problem on, he argues, because applicants apply to multiple specialties.

Dr Bhagia suggests a way to reduce competition ratios could be to restrict signatories to Certificate of Readiness to Enter Specialty Training forms, which can currently be signed by consultants worldwide, to UK consultants only.

He also suggests IMGs should be asked to complete at least one year in the NHS, at F2 level, before becoming eligible to apply for specialty training, which he says this would work in tandem with existing GMC registration processes and would ‘ensure fairness while maintaining high standards’. However, The Doctor understands this idea has been explored by RDC, and found to only delay, not solve, the competition issue.

‘The only thing IMGs want is an equal playing field,’ says Dr Bhagia. ‘We are even willing for the pathway to be made slightly tougher for us, because we see the issue holistically and can be fair. However, we will not accept being treated as second-class doctors, deprioritised compared to colleagues working the same rota, just because of where we graduated.’

Prof Kar believes ‘lateral thinking’ is required to find an amicable solution, which involves ‘looking at the whole picture’.

He thinks that, if the stated aim is to increase levels of domestic doctors, workforce planners need to ‘turn off the tap’ of international graduates. To do that, he suggests reducing the frequency of the GMC’s ‘cash cow’ PLAB exams for overseas doctors to prove their competency, which cost £1,271 for both parts.

‘Once you’ve done PLAB, no one can stop an IMG from applying for a job in the NHS,’ he says. ‘The question is, is the GMC going to look at matching the frequency of the PLAB exams to the demand in the workforce, or are they going to just keep flooding the system? There are plenty of doctors in the UK, there just aren’t enough trainee jobs. If there aren’t enough doctors, why are so many not in jobs?’

Dr Bhagia agrees that a reduction in PLAB exams should be considered, noting that there are other pathways for IMGs to attain GMC registration.

Dr Craddock supports a ‘temporary halt’ on PLAB exams and backs the stance that IMGs already working in the UK are ‘grandfathered’ into any changes to training eligibility, so their career progression opportunities are protected.

Prof Kar also suggests converting a number of LED posts into training posts to ‘take away the heat’ by reducing bottlenecks with less financial outlay than just adding more training places.

However, he noted doing that would still eat into consultants’ limited training time, which may be politically unpalatable for a government committed to driving down huge elective waiting lists.

The GMC’s workforce report notes that between 2016 and 2022 there has been an increase in the number of doctors in training per supervisor across all specialties except public health.

Prof Kar says: ‘Forget where the money is going to come from, where are the trainers? They’re talking about PAs [physician associates] being supervised by consultants, but the same consultants don’t have time for the existing residents. The maths doesn’t add up.’

As a solution, he suggested thinking about making greater use of specialist, associate specialist and specialty doctors to conduct training, perhaps specifically for doctors coming from LED roles because many in both cohorts are IMGs.

‘SAS doctors don’t get protected training time like consultants do. Why not? They are senior clinicians and might have a better understanding of LED issues. People need to start thinking along those lines.’

He also suggested having a resident doctor representative in the workforce planning team to help NHS England listen to their concerns, as well as a workforce specialist who is ‘not necessarily a doctor’ to help rethink the current strategy.

NHS England, for its part, has launched a review as it bids to make postgraduate medical training the ‘best in the world’. The review will cover placement options, the flexibility of training, difficulties with rotas, control and autonomy in training, and the balance between developing specialist knowledge and gaining a broad range of skills. The BMA is urging NHS England to prioritise this issue in the two years before its abolition.

Training bottlenecks are not just a problem in England. Doctors in Scotland have reported similar fears about the potential cliff-edge facing resident doctors completing their foundation years, and a report to the Welsh government on addressing NHS workforce challenges pointed to ‘limitations on the number of training places that can be commissioned’.

The RDC motion has been written to align with longstanding BMA policy which maintains that all doctors currently practising in the UK, regardless of nationality or place of primary medical qualification, should have access to training opportunities prior to recruitment from abroad.

The association’s chief officers accept the ‘very real crisis experienced by resident doctors seeking access to specialty training and the avoidance of unemployment’. In January, they issued a statement saying ‘specialty training bottlenecks are an aspect of the workforce crisis that has debilitated the NHS and cannot continue,’ adding that successive governments have ‘either exacerbated the problems or only sought to address them with unfunded and vague commitments.’ 

Those in support of the RDC’s position say the UK is an outlier when it comes to prioritising home graduates. In Australia, for example, IMGs from nations with recognised qualifications, such as the UK, must complete a supervised year as a resident doctor before applying to specialty training. In some specialties, such as surgery, applicants must hold either citizenship or permanent residency to be eligible.

But in a global market for doctors, and the World Economic Forum estimating a shortfall of 10 million doctors by 2030, critics fear prioritising home graduates for specialty training may put IMGs off applying for jobs in the NHS at all.

Prof Kar said senior IMGs, such as himself, have a ‘responsibility’ to communicate UK training bottleneck concerns to medical bodies in their home countries, so that IMGs understand the level of competition to get a job, and specialise, in the UK. This, he adds, is particularly important in ‘red list’ countries which themselves have doctor shortages.

But he insists: ‘We need to be bold enough to talk about this. Putting our heads down and thinking it will blow over is not a strategy.’

Dr Craddock says: ‘We must recognise that medicine is no longer an attractive career for hard-working young individuals in the UK. Their talents are often better placed elsewhere where the effort/reward ratio is far greater.

‘One of the few redeeming factors for medicine within the UK was job security, which all but recently was almost guaranteed. If we find ourselves in a situation where doctors who have graduated from our own medical schools are unemployed or frozen out of training, where does that leave medicine as a career within the UK?’

Dr Bhagia concludes: ‘Simply increasing training numbers without strategic planning would only shift the bottleneck to consultant-level jobs. What is needed is proper workforce planning to determine the number of consultants and middle-grade doctors required, then increasing training numbers slightly above that level to account for natural attrition post-certificate of completion of training.

'Unchecked expansion without planning will only lead to a new crisis down the line.’

While the solutions to this problem are up for debate, one thing is agreed by doctors across the board: specialty training bottlenecks need to be relieved, and soon.

(Main image credit: BMA / Andrew Bainbridge)