Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: Retention, not just training, is key

BMJ 2023; 381 doi: (Published 06 June 2023) Cite this as: BMJ 2023;381:p1272
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

Achieving a place at medical school is the ambition of many school leavers. Competition is intense, and a lot of young people who could become excellent doctors don’t have the opportunity to train. It would be to their benefit, and that of the wider public, if the much trailed expansion of medical school places actually came to fruition,1 but details remain uncertain. The long awaited NHS workforce plan, which might give clarity, is coming “soon,” say government sources.2

There are a lot of issues to sort out, including whether the necessary resources have been identified to provide the teaching and supervision these new students will need. The 40 new hospitals we were promised would have added to the number of appropriate clinical teaching environments, but it seems that we’ll have to wait a long while for those too.3

However, there’s no point in filling a leaky bucket. You can turn the tap on harder by increasing the number of doctors in training, but it would be more efficient to look at why so many qualified doctors are leaving the NHS and to focus on how to retain them. Some students realise as they study that they’ve made a mistake and that medicine really isn’t the career for them, so they move to another. But these few are greatly outnumbered by those who love the job but won’t put up with the way they’re treated in the NHS. As a result, the UK has become a net exporter of doctors to the rest of the world, with one in seven UK trained doctors now working overseas.4

Partly this is about pay, with a huge real terms loss of earnings in the past 15 years. But it’s also about a lack of respect, demonstrated by late and inflexible rotas that deny people leave, sometimes even for their own wedding.5 Some hospitals have no access to hot food (or, on occasion, any food at all) or places to rest during night shifts. The infantilising assessment forms shared on Twitter last week about participation in postgraduate training might have been the last straw for me if I was currently in foundation years.6 The junior doctors who persist as far as general practice training will work hard, but they have the advantage of little out-of-hours commitment and well protected educational time. We tend to lose those doctors later, when they complete their specialist training and make the huge leap into the overworked world of the qualified GP.

As the pool of available doctors shrinks, the work gets harder for those who remain, and so we spiral downwards. Training more doctors is part of the answer, but retention is key. I wonder if the currently suggested plan to reduce the length of doctors’ training would also have implications for their international mobility?7 After all, a cynic might suggest that one advantage of having doctors who are less highly trained would be that no one else would want to employ them.