Intended for healthcare professionals


Doctors in training should be at the top of the workforce priority list

BMJ 2024; 385 doi: (Published 08 May 2024) Cite this as: BMJ 2024;385:q1045
  1. Alexander Mafi, editorial registrar
  1. The BMJ, London

Giving greater attention to the specific challenges facing doctors in training is a necessary step towards improving working conditions and wellbeing, writes Alexander Mafi

The working conditions of doctors in training have had a brief moment in the spotlight following a recent letter from NHS England (NHSE) to NHS trusts urging measures to improve our working lives.1 While it’s encouraging to hear a call for nationwide action to tackle the challenges facing doctors in training, this letter is only a small first step to achieving that goal.

The letter, sent by NHSE’s chief executive Amanda Pritchard, lays out several action points for hospital boards. It includes welcome recommendations to reduce the time burden of statutory mandatory training, increase attention to payroll accuracy, and improve rota management and deployment. NHSE’s commitment to monitoring compliance with rota regulations and providing intensive support to payroll teams is also promising. Many trainees will have experienced the mental and emotional drain of having to argue over unfair parking charges or payroll errors or dealing with financial pressures caused by waiting months to recover course fees. A former colleague is yet to be paid over £1000 for a set of night shifts—despite six months of his best efforts, he’s now given up. It’s encouraging to hear that there could be progress made on this front.

At the same time, the letter makes for a disappointing read. The non-committal language and the focus on what many trainees might consider the bare minimum doesn’t offer much hope. The recommended changes in the letter, while positive, will do little to tackle the deeper problems experienced by doctors in training: the minimal professional autonomy, the lack of a sense of belonging, and the shrinking job opportunities to name a few. Doctors in training have been neglected for a long time, clear from the continuing exodus both from the UK and from the profession, the unwaveringly high support for strike action, and the persistently low morale.234 We were notable only for our absence in the NHS Long Term Workforce Plan last year, referenced in NHSE’s letter.5 In particular, the plan’s extended focus on developing an expanded workforce of new clinical roles, at the expense of investing in doctors, made for frustrating and disheartening reading. This neglect is coming at a price, with figures produced by the BMA suggesting that the current exodus of trainees is costing the health service up to £2.4 billion a year.6 While the concern is sorely needed, it needs to be matched with action. Although doctors in training are already making strong demands of the government around pay and conditions through strike action, a holistic approach is needed that involves change at all levels of the health service.

An open consultation with training and rotational doctors would be a key early step in setting priorities. Hospital trusts should also commit to routine inclusion of training doctor representatives within the highest levels of hospital management to regularly highlight the perspectives and issues of early career doctors. These early career voices should reflect the diversity of trainees and will be particularly important in confronting the challenges experienced by underrepresented and underserved trainees who are most at risk of burnout and alienation. Many of the required improvements are long standing and well known. Trusts, for example, should commit to providing adequate rest space for on-call doctors, ensure appropriate junior staffing of wards, and reliably offer rota flexibility for life events and after traumatic experiences at work to prevent burnout. Adopting measures recently proposed by Silver and colleagues to improve a sense of belonging would be similarly valuable to improve retention and job satisfaction for rotating doctors.7

At the national level, NHSE and health education bodies across the UK urgently need to tackle the uncertainty around the geographical location of jobs that training doctors experience. In particular, the four UK health education bodies must take action to solve the current shortfall in foundation jobs and improve the three weeks notice that incoming foundation doctors are being offered.8 A wider consultation on reversing recent changes in the foundation allocation system is also needed to restore some autonomy for medical students over their foundation school placement as well as longer term efforts to ensure appropriate job planning for future graduates. Universal support for less than full time working and for trainees taking maternity or paternity leave, and a long term commitment to initiatives to support health and wellbeing like the Practitioner Health programme, would all help to improve and protect trainee welfare.

Finally, the value and importance of doctors in training within the health service must be recognised by the government. This should be reflected by resolving ongoing pay disputes and an urgent reinvestment in training places. Understanding that these challenges can’t be overcome without coordinated multi-level system change, and an allocation of the resources necessary to achieve this, will save us all a lot of time, energy, and money.

The letter from NHSE is a good start. But it is the beginning of a long journey towards improving the conditions and wellbeing of doctors in training.


  • Competing interests: None.

  • Provenance and peer review: Commissioned, not externally peer reviewed.