Medical training at breaking point: will an increase in learners push the system over the edge?

Matching education capacity to expansion

“Delivering medical education feels like one of the biggest challenges in the NHS right now,” says Simon Frazer, chief executive officer of DoctorsTraining, which employs 70 medical trainers to deliver training programmes and workshops for senior doctors and consultants across the NHS. Frazer, who has been involved in medical training for over 20 years, says, “I think most doctors are very passionate about supporting training, but I think they are finding that harder and harder to do.

“They’re worried about how they will keep up that extra effort without more training capacity and protected time. I think they are feeling a bit overwhelmed about the expansion in the workforce needing their support. They’re worried about the longer term demands as the number of staff needing training increases.”

Billy Palmer, senior fellow at Nuffield Trust, says that the capacity to train doctors is one of the most pressing challenges for the health service. “It has become a real problem and has to be addressed urgently to have any success for the long term workforce plan being delivered,” he warns. The previous government stayed silent on how the NHS can create enough trainers, he says. “The workforce plan does not explain how sufficient numbers of academic and clinical educators and supervisors can be found from the current NHS clinical workforce that is often already under too much pressure. We have been concerned about that from the outset.

“The ratio of supervisors to people needing education has suddenly shifted very rapidly, and the health service is going to struggle to keep up with that,” he warns. “Not only are we having the expansion of medical school training places, but we’ve also got the expansion of physician associates, advanced clinical practitioners, and, in some cases, they are drawing on the same supervision capacity—so sometimes looking at the same consultant to provide their education.

“We are seeing things getting worse in that medical training pipeline over time. We have a real leaky pipeline, and I would question whether the current system is working.” Retention rates support that view. Only a third of doctors completing their foundation training continue to the next stage straightaway, according to data analysed by the Nuffield Trust.3 Many decide to take a break, and not all return to work for the NHS. “We think we lose about one in eight—every year we see a higher proportion opting to take a break,” says Palmer.

As for doctors in core training, around 40% have left the NHS within eight years. “That points to a problem. They might go on and pass their exams, but, from a public taxpayer perspective, you also want them to join and remain in the NHS. By providing people an inadequate and stressful education, there’s a real risk they’re less likely to join,” Palmer says.

There are other quantitative indications that medical training is under pressure. The General Medical Council (GMC) conducts an annual UK-wide survey to ask trainees about the quality of their training and trainers about their experience as clinical or educational supervisors.

The 2024 survey found that, although most trainers (90%) said that they enjoyed their role as medical educators, 27% said that they didn’t think their job plan had enough designated time for their role as a trainer.4 Less than half (48%) said that they were always able to use the time allocated for training specifically for that purpose.

The percentage of trainers reporting burnout has remained broadly similar since 2022, with 50% measured to be at high or moderate risk of burnout and a third (32%) saying that their work frustrated them to a high or very high degree. The survey also found that 31% of secondary care trainers think that their trainees’ education and training were adversely affected because rota gaps weren’t always dealt with appropriately.

The regulator said that, for England’s workforce plan—alongside those in Northern Ireland, Scotland, and Wales—to succeed, additional capacity needed to be created with the expansion of the educator workforce. The GMC’s medical director, Colin Melville, said, “Plans to increase medical school places are much needed and welcomed. However, to ensure these places produce the skilled doctors of tomorrow, we also need to increase the number of educators and provide them with the necessary time and support.”

In January the Royal College of Surgeons of England published results of its annual census of members.5 Findings also indicated a workforce under huge strain due to excessive workloads, a factor that had a knock-on effect on education. Up to 52% of surgical trainees said that they did not have sufficient training time, and 61% said that they lacked access to theatres. “The pressures of service provision prevent them from attending training sessions both in the clinical environment and in educational settings,” the report noted.

Extra workload on consultants

David Oliver, consultant in geriatrics and acute general medicine at Royal Berkshire NHS Foundation Trust, says that as more groups of staff require postgraduate training, more work is falling on consultants to provide it. “We train all levels of doctors, from medical students up to specialty registrars, and then we’re adding on medically associated professionals on top, and it all falls on the same consultants to do that training. On top of that, there’s also big pressure on consultants to focus on things like waiting list initiatives, urgent care waiting times, and improving patient flow in hospitals.”

He adds, “Meanwhile, of course, consultants have big gaps in their own workforce and rotas and a lot of competing demands on their time.”

Partha Kar, consultant in diabetes and endocrinology at Portsmouth Hospitals NHS Trust as well as the national lead in diabetes for NHS England, agrees that demands on trainers have grown exponentially. “In my job plan, I have time to properly supervise four doctors, but I currently have seven. I’m a supervisor to seven trainees across all different levels. This is a pretty typical picture, so it means the system relies on a huge amount of goodwill to get things like annual appraisals done,” Kar says.

Acknowledging that the workforce plan has recently been somewhat discredited as “overly optimistic” by the spending watchdog,7 Kar says that confidence in NHS England’s Workforce, Training and Education Directorate is now low. “I have lost confidence, and you would struggle to find anyone or any organisation right now that would give it their unequivocal support. We have a workforce plan that is clearly not working, and it’s impossible to deliver it on the budget given.”

The BMA took its concerns to the electorate, by making training part of its manifesto ahead of the general election. The government must tackle these bottlenecks with additional funding, it says.

David Strain, BMA medical academic staff committee chair, says, “The long term workforce plan promises that any expansion in medical school places is going to be matched with a sufficient number of specialty training places. We made clear in the BMA’s election manifesto that any new government will need to properly fund these promises.

“That means ensuring sufficient clinical educationalists to ensure the quality of trainees’ education does not suffer and support for educational development. Without that resourcing, the kind of training bottlenecks we have already seen are only going to get worse.”

Impact on teaching

Meanwhile, the burden of ensuring that training happens often falls on trainees themselves. “Being on a training contract doesn’t necessarily mean doctors get trained,” says Shonnelly Novintan, a core surgical trainee at Colchester Hospital and a representative of the Doctors’ Association UK.

“I was fortunate to have a good six month placement in breast surgery recently. I had good trainers who would discuss each case and give me feedback, and then because I was in theatre the week after, I could practise what I’d just learnt,” says Novintan. “In previous jobs, I’d go to theatre once a month. You can’t consolidate skills in that time. In my current job, I had to take on the voluntary job of being a rota coordinator—managing all the duty rotas—to ensure I get to theatre once or twice a week.”

Foundation doctors report the same problem with taking up learning opportunities. Penelope Sucharitkul, a foundation year 1 doctor based in Bristol and training under Severn Postgraduate Medical Education, says that if there are staff shortages, trainees are often unable to get to their training. “Deaneries put on simulations, which are good, but it’s four hours off the ward, which is impossible for most doctors. I’ve struggled to get my annual leave, let alone take any study leave.”

Nicola Cooper, consultant physician, former training programme director, and a clinical supervisor and teacher, says that doctors should be able to expect that someone has looked at their curriculum, understands the requirements, and is delivering it. But this is not the case. “It’s turned into a situation where doctors in training and locally employed doctors are regarded solely as employees who have to fight to get their training along the way,” she says.

“It is now difficult for doctors in training to leave the wards to attend classroom teaching or other learning opportunities. And quality teaching and learning on the shop floor is often lacking, in part, due to the clinical pressures everyone is under,” Cooper adds. “This means they sometimes have to fight to get study leave, to go to courses, to get the training opportunities they need. Often, junior doctors have to escalate issues to get their training arrangements sorted.”

The result is that specialty training is very patchy and varies by specialty. “Over time, we seem to have arrived at a situation where we are aiming for competence rather than excellence in our medical workforce,” Cooper says.

Educator workforce strategy

Hardly a ringing endorsement for Navina Evans, chief workforce officer at NHS England, or the civil servants that helped put together plans for a sustainable workforce for the NHS. The BMJ asked her and her team several questions. In response, NHS England issued a statement saying, “The NHS is taking action to improve working conditions and retention as part of the NHS long term workforce plan, including increasing choice and flexibility in rotas and reducing duplicative inductions and training.

“We know there have been concerns about sufficient educator capacity, and that is why we are implementing our educator workforce strategy. This includes introducing guidance and metrics for integrated care boards, developing a career framework for educators, and collating and sharing best practice. Together, all these measures will improve the quality of education, training, and patient care.”