The state of medical education and practice in the UK: workforce report 2023

Executive summary

Even with the expansions of medical school places, continuing to attract skilled and experienced international medical graduates will be crucial

The UK’s healthcare systems are experiencing a prolonged period of high pressure, with industrial action, backlogs in elective care persisting, and a shortage of doctors that ongoing high vacancy rates evidence.

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Foreword

When we wrote our foreword to this report last year, we warned that urgent changes were needed to ensure the sustainability of the UK’s health workforce.

Since then, we have seen the publication of NHS England’s NHS Long Term Workforce Plan, with its welcome commitment to double the number of medical school places.

However, it’s important to remember that it takes a long time to train a doctor. Even if the plan is smoothly implemented, with equivalent further commitments in Northern Ireland, Scotland and Wales, the benefits will only start to be seen a decade from now.

In the meantime, doctors from overseas will continue to make up the bulk of those joining the medical register. Thankfully, the UK is still seen as an attractive place to work. International medical graduates (IMGs) made up over half (52%) of new additions in 2022. Our data show that they are playing a crucial role in all areas of the medical workforce and there have been particularly large increases in IMGs in general practice. The health services must continue to attract these talented doctors, facilitate their transition, and empower them to provide safe patient care. For our part, we have recently increased our investment in our Welcome to UK practice workshops which provide IMGs with a better induction, helping their transition and giving them the chance to connect with other internationally qualified doctors.

It’s clear that regardless of where doctors have trained, and the kind of training pathway or employment approach they choose, every individual should feel welcome and supported. They should be provided with the tools and working environment they need to find job satisfaction and reach their potential.

Our data show that an increasing number of doctors are seeking opportunities to work in more flexible ways. More doctors work part time, and more medical students and doctors in training are looking for greater flexibility in their training pathway. Many of these changes will have longer term benefits. We know, for example, that post-foundation training breaks can help reduce the risk of burnout and build confidence in next steps. For some, they help provide certainty over choice of specialty. And many cite wellbeing or personal fulfilment as a reason for taking a break. This pause in the pathway needs to be viewed positively and accommodated within workforce planning and training opportunities.

The number of specialty and associate specialist (SAS) doctors and locally employed (LE) doctors on our medical register have increased substantially. Doctors working in these roles now make up almost a quarter (24%) of our total workforce. Too often these doctors have been treated as a single homogenous group, which does not help our health services get the most out of their skills. More needs to be done to ensure that these professionals are recognised for what they have to offer; that they feel valued and are supported to progress their careers. We are pleased that for the first time this year, we have been able to provide separate data on SAS doctors and LE doctors, which give us a more useful basis for analysis.

We are also able to report that the medical register is more ethnically diverse, partly due to the growth in the number of IMGs, but also due to broader diversity within UK graduates. This increasing diversity in the workforce is undeniably a positive thing, but healthcare leaders across the UK must ensure that workplaces are appropriately inclusive and supportive. If they are not, it is patients as well as doctors who will suffer. Fewer doctors will stay on if their experience is not a positive one, regardless of their background.

Earlier this year, we published the results of our annual survey of the profession, which showed a worrying jump in the number of doctors who said they found it difficult to provide sufficient patient care at least once a week. At a time when so many areas of the health services are under pressure, policymakers must redouble their efforts to ensure that all doctors are deployed and supported in ways that maximise their contribution to safe patient care. Getting this right will benefit patients and enable us to retain the doctors we need in the years ahead.

It's also vital that the health services keep pace with the changing composition, needs and wishes of the profession and the evolving demographics of the UK population. Embracing diversity, ensuring equity in every form, and providing more flexibility in training and career pathways, could help both retain and attract talented doctors to UK practice. Resistance to new ways of thinking and working cannot be allowed to stand as a barrier to improvements.

There are rich and enlightening data here. We hope they will help policymakers and healthcare leaders from all four countries of the UK to steer a course through the difficult times ahead. Good patient care, now and for the foreseeable future, depends on their swift and decisive response.

Overview of the workforce

Summary

• The number of licensed doctors continues to grow. Since 2019, the number of doctors joining the workforce each year has been more than double the number who leave. In 2022, 23,838 doctors joined and 11,319 left. This growth continues to be strongly driven by international medical graduates (IMGs) joining the UK medical profession.
• The number of IMGs joining the General Practitioner (GP) Register has almost tripled (+192%) from 2018 to 2022, whereas the number of UK graduates becoming GPs has fallen slightly (–4%). The UK’s healthcare systems must address why general practice appears to be less attractive to UK graduates, which will require efforts to resolve the persistent issues in workloads and other indicators of burnout that GPs report.
• A proof of concept method combining register and National Health Service (NHS) contracts data for doctors in England and Wales shows there are clear differences between specialty and associate specialist (SAS) and locally employed (LE) doctors. For example, 82% of SAS doctors had been licensed for five years or more compared with only 35% of those who hold LE contracts – which is linked to the terms and conditions of a SAS contract.
• There is an ongoing shift within the SAS and LE doctors group in England and Wales, with the LE group growing far more quickly than those on SAS contracts. From 2014 to 2021, LE roles became by far the largest component of the group. By 2021, the number of LE doctors (22,576) was more than double the number of SAS doctors (10,349) in England and Wales.
• The retention of IMGs who join as LE doctors is improving, and we also see increasing proportions of these doctors later enter postgraduate training. Of the IMGs who joined as LE doctors in 2014, 37% had left after four years, but only 20% of the 2018 cohort did so. In terms of postgraduate training, 26% of the IMG LE doctors who joined in 2014 were in training four years after joining, which increased to 39% for the 2018 cohort.
• The number of doctors leaving each year has increased (from 9,825 in 2021 to 11,319 in 2022) but the proportion of the workforce leaving (4%) is only returning to pre-pandemic levels. However, we are aware of the increasing numbers of doctors taking hard steps towards leaving the profession.

Doctors joining the UK workforce and the UK training pipeline

Summary

• Medical student intakes have reduced slightly after two pandemic affected years increased the numbers. The UK’s 2022/23 medical student intake was mostly female (62%), and especially so in Northern Ireland (72%).
• In a pattern that has held since 2012, females make up a greater proportion (57%) of doctors in formal postgraduate specialty training. However, in certain programmes there remains a gender imbalance. For example, obstetrics and gynaecology was 83% female in 2022 and, conversely, surgery was only 36% female.
• The number of international medical graduate (IMG) trainees increased across most specialty training programmes, but especially in less competitive ones such as general practice, where the number of IMGs grew by 86%. This may be in tension with an aim of National Health Service (NHS) England’s Long Term Workforce Plan, which had an aim to emphasise the supply of general practitioners (GPs) with a UK primary medical qualification (PMQ).
• A growing proportion of doctors take an increasing amount of time away from training after their second foundation training year—with most actively choosing to do so, as opposed to being forced to. Commissioned research shows time away from training helped doctors to confirm their preferred specialty training and to gain clinical competencies.
• The pace of progression through postgraduate training varies across specialty programmes and levels. For example, 40% of pathology specialty training level five (ST5) doctors and 39% of obstetrics and gynaecology ST5 doctors needed more than a year to progress. This can mostly be explained by doctors working less than full time or taking time away from their training posts to carry out research, build their wider experience, and take parental leave.
• There needs to be adaptation within the UK’s healthcare systems to this new reality of less linear postgraduate training pathways. The ways in which doctors develop their skills and knowledge often come from a broader range of experiences in a wider variety of settings than may have been the case historically. Building this understanding into the evidential requirements for joining the Specialist Register or GP Register will be important and legislation coming into effect this November will make that possible.

Doctors leaving the workforce

Summary

• The number of doctors leaving has increased in the last year. However, the proportion of licensed doctors leaving has only returned to pre-pandemic levels of just under 4%. At the same time, we know many doctors are taking hard steps towards leaving, so we must remain vigilant about the issues driving them to leave the profession.
• The proportions leaving in each UK country were very similar in 2022, and were within half a percentage point of one another (3% to 3.5%) from 2017 to 2022. There was a much higher leaving rate among doctors who could not be located in 2022 (26%), which increased the overall rate slightly, to 4%.
• A relatively large proportion of the specialty and associate specialist (SAS) and locally employed (LE) doctors group leaves each year (8% in 2022), compared with the 4% of all licensed doctors. However, the leaving rate was considerably lower in this group among those who had held a SAS contract (3% in 2022), at similar rates to general practitioners (GPs) (4%) and doctors on the specialist register (3%).
• Doctors who join after sitting the Professional and Linguistic Assessments Board (PLAB) exam have a similar retention rate to UK-trained colleagues. Of those who joined between 2012 and 2018, 87% of international medical graduate (IMG) PLAB doctors were still licensed four years after joining, compared with 91% for UK graduates.

The future workforce

Summary

• If the trends from 2017 to 2022 were to continue, the workforce would grow by 51% by the end of 2036, compared with 2022. This is assuming a continued growth of around 3% per year, which is primarily driven by international medical graduates (IMGs) joining the workforce.
• However, planned increases to medical school places around the UK, the coronavirus pandemic, and the National Health Service England (NHSE) Long Term Workforce Plan (LTWP) mean the recent trends will not carry forward. We estimate these initiatives and events would result in there being 47,905 more UK primary medical qualification (PMQ) doctors joining the workforce by the end of 2036 than there would be if the numbers held at the level seen in 2017/18. It is crucial that the increasing cohorts of UK graduates entering the workforce are fully supported and their training needs met.
• Even with a further hypothetical increase in UK graduates—and an assumption that each UK graduate replaces an IMG who would have otherwise taken the role—the future workforce will still rely on the skills and expertise of IMGs. In this scenario, just under a third (32%) of licensed doctors in 2036 would be IMGs. Should the assumption not hold, and the extra UK graduates are in addition to IMGs, 36% of licensed doctors would be IMGs in 2036.
• It is vital that all workplaces have inclusive and supportive cultures that successfully induct and integrate doctors from a wide range of backgrounds.

Conclusions and key insights for workforce planning

Summary

• The number of licensed doctors continues to grow rapidly, with those joining outnumbering those leaving by more than two to one since 2019. However, there are still high vacancy rates and workforce pressure.
• Over half (52%) of new joiners in 2022 were international medical graduates (IMGs). 

• Even if the ongoing and planned increases to UK medical school places are complemented by a replication of NHS England’s NHS Long Term Workforce Plan (LTWP) in all UK countries—and if those future UK graduates were to replace future IMG joiners—the UK’s healthcare systems would still need large numbers of doctors to continue joining from abroad. Welcoming, integrating, and retaining all doctors who join from abroad will be crucial to meeting the UK’s future healthcare needs.

• The proportion of doctors leaving the workforce has only returned to the pre-pandemic level of just under 4%. But there are worrying signs. A growing proportion of doctors plan to leave the profession as a result of high levels of dissatisfaction and high risk of burnout. We may be in a limited window of opportunity to address current issues before they manifest into larger proportions of doctors leaving the profession.
• The growth in the specialty and associate specialist (SAS) and locally employed (LE) doctors group appears to be mainly driven by those taking up LE roles as opposed to SAS roles. In 2021, there were more than double the number of LE doctors (22,576), compared with SAS doctors (10,349), working in England and Wales.
• The LE doctors cohort has grown because of both IMG joiners and the increasing proportion of doctors who are taking longer periods of time away from formal postgraduate training after their second foundation year (F2).
• As well as taking time away from training after F2, there are training stages within programmes that many doctors take longer to complete than the minimum possible time. Our data show that undertaking research and gaining experience in a different post partly explain why some training levels take longer than others.
• The UK’s healthcare systems must evolve to take advantage of the upsides in the broader range of experiences that doctors are building. Adding flexibility to the evidential requirements for joining the Specialist Register or GP Register will be important and legislative changes mean that is now in progress.

Downloads

• Reference tables about doctors in training
• Reference tables about fitness to practise
• Reference tables about the register of medical practitioners
• Reference tables about the register of medical practitioners by country and region
• Reference tables about doctors who are trainers
• Regional reference tables about fitness to practise
• Reference tables about reasons for leaving