Major review recommends urgent reform of medical training in England

A major new review has recommended that ‘reform of postgraduate medical education and training is undertaken as a matter of urgency’ in England.

The review, led by chief medical officer Professor Sir Chris Whitty and NHS England national medical director Sir Stephen Powis, includes recommendations on making training more flexible, widening access to training, reviewing the balance of international versus UK graduates entering the system, and placing a stronger focus on all doctors having more generalist knowledge.

Competition for GP specialty training posts has reached a record high, with five doctors now vying for every available place in England, the report said. It suggests that looking at the ratio of international medical graduate (IMG) entrants to UK-trained doctors may be one part of addressing rising competition and bottlenecks in the system.

It said this comes amid a ‘crisis of confidence’ among the profession created by training bottlenecks and rapidly increasing competition ratios for specialty places.

The report said: ‘We heard very clearly that although many aspects of postgraduate training work well, the current model does not always serve the professional development needs of doctors or meet the population and patient health needs for the future.

‘We know that since the last set of major reforms the way postgraduate medical training is delivered has continued to evolve. However, in our view it is now no longer a sensible option to rely on this unplanned evolutionary approach by Royal Colleges, NHS England, deans and the GMC.’

Noting that IMGs make up 52% of GP training programme places – the highest among any specialty – the review said ‘consideration’ would be needed of the ratio between new IMGs entering UK training and those already working in the NHS.

It said: ‘Addressing bottlenecks at all points in training and development should be considered urgently. This will have to include consideration of the right ratio between new international graduate entrants to medicine in the UK and those who are already working and training in the NHS, taking into account the workforce need.’

However, the review also raised the issue of ‘structural inequalities’ specific to IMGs, including cultural adaptation, limited induction support, lack of structured mentorship and unconscious bias in supervision.

The report also said rising multimorbidity means doctors must be able to manage multiple conditions and provide holistic care, rather than focusing narrowly within a specialty. ‘Curricula and training programmes must ensure that doctors are able to maintain a core set of generalist skills as they specialise,’ it said.

And it recommended a strategy to better support trainers, reduce bureaucracy and provide sufficient protected time. The strategy should ‘deliver educators who are supported and enabled to train the future medical workforce in a fit-for-purpose environment and with transparent funding’ and should ‘be a fundamental part of NHS reform’.

A further recommendation addressed tension between service provision and training quality. It suggested ‘all doctors working in the NHS should be supported to progress’ and the differentiation between ‘training’ and ‘service’ roles should be made less rigid for doctors early in their careers.

A review of rotational structures, which is already underway, must aim to ‘deliver a medical workforce able to care for the population while reducing the personal impact on resident doctors and the bureaucracy of current models’, the review added.

Professor Whitty said: ‘Training is essential for good medical practice and patient care and all doctors are involved both in being trained and in training others from the start to the end of their career.

‘This report sets out key areas where medical training is working well and where it isn’t working well and needs reform. It is now for us as the medical profession to weigh up the trade-offs and put forward solutions to improve medical training and ensure the profession is fit for the future.’

RCGP GP registrar co-chair and resident doctor representative Dr Deepthi Lavu said: ‘Resident doctors are deeply committed to providing the highest quality care to their patients. However, the current medical training system presents significant challenges when developing the skills needed to deliver the care our patients truly deserve.

‘The thousands who engaged with the review so far reflect the profession’s strong desire for meaningful change and, more importantly, their willingness to actively contribute to shaping it. These recommendations mark a pivotal step towards long-awaited and much-needed reform driven by the profession itself.’

Last month, the RCGP and BMA wrote to the Government demanding a ‘permanent, sustainable solution’ to visa sponsorship issues for IMG GPs. IMG GPs, who typically spend three years completing their training in the UK, are unable to meet the five-year threshold to apply for Indefinite Leave to Remain upon qualifying.

The NHS 10-year health plan, published earlier this year, pledged to hire no more than one in 10 NHS recruits from overseas by 2035.

The latest GMC annual training survey found that while fewer GP trainers were at ‘high risk’ of burnout, they still responded more negatively than average to burnout-related questions.