Specialty Medical Training

Question for Short Debate

14:00:00

Asked by

To ask His Majesty’s Government what assessment they have made of the ratio of medical training posts in each specialty relative to the number of foundation year medical students choosing that specialty.

My Lords, I am very grateful for the opportunity to raise this important issue. Although it will be a short debate, this is not an unimportant subject for us to discuss. It is also very timely, coming just a fortnight after the Government’s publication of Fit for the Future and the 10-year plan. I will refer to that in some detail a little later, but it is timely for us to look at the Government’s statements in that plan and how they are to be delivered. This autumn, something approaching 24,000 young people will go to medical school. They are among the most intelligent, passionate and motivated young people. Among many of them, there is an understanding that it is a competitive profession and that they will have to fight for their places: 24,000 of them might seek medical school places but only around 9,000 or 10,000 will achieve that. From the outset, it is a competitive situation. However, we do not want to make that competition a career-frustrating experience—something that does not enable them, having achieved their initial medical qualifications, to set out on their career. We want them to be able to see that through to a more successful conclusion. One of the central issues is that, once upon a time, there was an expectation that there was a flow from initial medical school into foundation-year training and that, following foundation-year training, the substantial majority of people would go into some form of speciality training. This is not an assumption that we can make to the same extent now, when the proportion going into speciality training straight out of foundation year 2 has gone down from something like three-quarters to only just over one-third. What we want is to follow through on the expectation that we can make a substantial contribution to meeting our own medical workforce requirements and, potentially, make some contribution internationally. The worldwide demand for doctors is rising. The World Economic Forum has estimated a global shortfall of 10 million doctors by 2030, so the fact that we are increasing the number of doctors and medical school places in this country should be welcomed, frankly, whether or not we subsequently employ all those young people in our own National Health Service. If they go somewhere else or work in other parts of the world, fine—so be it. We have always drawn on other parts of the world for our medical services here, so we should be comfortable with that future possibility. Indeed, the number of international medical graduates coming to this country has substantially increased, particularly after the 2020 revision of the shortage occupations list and the resident labour market test no longer applying. This has led to a substantial increase in the number of international medical graduates. We need to focus on that issue, alongside medical training, in some of our discussions this afternoon. When it comes to the relationships between the increasing numbers of medical school places, my noble friend may like to recall the successful expansion of medical school places over the past two decades; it happened before, while and after I was the Secretary of State, and it continues to this day. In 2023, the long-term workforce plan set an ambition—not just an ambition but a promise, I think—that there would be 15,000 medical school places by 2031. We are not far off track on that, but I am not entirely sure whether that continues to be the Government’s intention. However, the ratio for those applying to specialty training from medical school and foundation years has significantly deteriorated. In a number of specialties, we have seen substantial numbers of additional young medical graduates coming through after finishing their foundation year—for some specialties the number has doubled or even tripled—but the number of posts available for them in speciality training has in many cases hardly increased at all. Overall, there has been something like a 34% increase in medical school places but only a 9% increase in speciality training available. Noble Lords do not need me to remind them that the ratio of applications to places in some specialities is severely distorted. When looking at the numbers, you have to do some work to establish to what extent there are unique applications as well as the total number of applications, but, even so, overall there are more than twice as many applications for specialty posts than we have places available. In some specialties, the ratio is significantly higher. The Government’s report Fit for the Future made a number of important points, on which I think we all agree. As they put it, the Government wish to “tackle bottlenecks in medical training pathways”. One of the central ways they plan to do this is by working “to prioritise UK medical graduates for foundation training, and to prioritise UK medical graduates and other doctors who have worked in the NHS for a significant period, for specialty training”. We need to know a bit more about what is intended by this reference to “other doctors who have worked in the NHS for a significant period”. Are we talking about six months, a year, two years or five years? Making specialty training less accessible to international medical graduates will have a significant impact on the likelihood of their coming to this country to work in our NHS. We are not wholly reliant on that and should not be, but we need to know what the implications are. It could mean literally tens of thousands fewer doctors available in five or 10 years’ time. The Government also committed to 1,000 new specialty training posts over the next three years. I want to be sure that I understand this. Will they increase the annual supply of specialty training places by 1,000, which would be something like a 20% to 25% increase, or add 300 or so each year over three years? That would not be quite what we are looking for. I hope I will be assured that it will be a 20% or 25% increase in the number of places available. The Chris Whitty and Stephen Powis review of medical training is continuing and we expect to see the Government’s long-term workforce plan in the latter part of this year. I hope it will include greater detail about the expectations for the requirements for consultant posts and the consultant workforce in future years, specialty by specialty. I hope we will see more detail on the extent to which the Government expect UK graduates to remain in the NHS, and perhaps some incentives for them to do so, so that we do not rely as heavily as we have done in the past on international medical graduates. I hope that the review of medical training and the Government’s workforce plan will use the independent sector more, which supplies something like 10% of treatments overall and should supply a significant proportion of the training support available. I hope we will see more on supporting professional activities written into consultant job plans, because we cannot deliver the increase in specialty training that we are looking for without more of that being available. I hope that where the Government say that they want to work with the GMC to get a streamlined pathway to consultant status, that means that, in addition to the specialty training places, those who go into locum and locally employed doctor status can also find their way, through certificates of eligibility or experience, to becoming consultants in due course. I also hope that, overall, the workforce plan that we will see later this year gives us many more of the answers that we are looking for to enable us to deliver this improvement in the consultant workforce in future.

14:10:00

My Lords, I am grateful to the noble Lord, Lord Lansley, for having secured this important and timely debate, given that many doctors find in August that they are without jobs. Although those graduating in medicine in this country are guaranteed a pre-registration post, there are not enough posts for all of them in the UK. It is welcome that the Government’s 10-year health plan states that these UK graduates will be given priority for F1 posts—that is, the first year after coming out of university. In those posts, they are the responsibility of the parent university, as well as whoever is responsible for their training at local level. It has been estimated that there will be a need for at least 1,000 extra GP training posts in the very near future, to say nothing of extra medical educators, to recognise those shaping the future workforce. Although common things occur commonly, diagnosis of complex conditions is not done by simple algorithms. There has been a potentially dangerous overreliance on artificial intelligence. That is already being discussed at major medical conferences. We need the people with the training. Part of the welcome commitment in the Government’s plan is to reverse the decline in clinical academics, which must address the need to reimburse universities for the additional cost of the contractual arrangements for NHS substantive and honorary consultants. Worryingly, last year’s negotiations took place without the involvement of the universities or the Department for Education, yet, without research, all our medical advances and their benefits to the UK economy could dwindle. Medical schools are committed to widening participation in the profession, with a more than 50% increase now in the entrants from disadvantaged backgrounds, and a focus on under-doctored areas to strengthen the health economies of remote and rural regions, encouraging graduates who want to return to the areas from which they come. There are, however, major bottlenecks early in training due to a mismatch between training posts and numbers and available doctors between both FY2, the second year after qualifying, and internal medicine training, and then on into higher specialist training. This is contributing to a lack of workforce capacity in higher specialty training, and that feeds on into a shortage in the consultant workforce itself. I illustrate this from my own specialty of palliative medicine and from emergency medicine, two areas where the need for high-quality medical services is rapidly increasing because of demography and the complexity of multiple comorbidities, including presentations of new conditions and, in emergency departments, of major incidents. Competition for internal medicine training has grown rapidly. Taking into account multiple applications, there are still two doctors for every available post. Applications from international graduates doubled in the last year, and the increase from UK graduates was 33%. This leaves seven in 10 recently qualified and registered doctors concerned about their future employment, of whom a quarter were apparently unsuccessful in applying for specialty training. More than one in 10 are now applying for medical jobs abroad and more than one in five are looking for an alternative career. One area of great pressure is the number of formal training posts. If a post is taken by a doctor who then works less than full-time, the unused part of that post cannot be filled because there is no additional marginal funding. Job shares are difficult and sometimes do not work well, and internal medicine shows that almost two-thirds of certain speciality trainees are working less than full-time. This then feeds through to the shortfall in trained doctors eligible for consultant posts, leaving many vacant palliative medicine posts, for example, unfilled for prolonged periods because flow-through is stagnant due to funding constraints. It is worsened by the reliance on charitable funding for some of these posts. For example, a colleague of mine in west Wales is struggling to do the job of three consultants because two posts are vacant due to a failure to fill these jobs because of a shortage of suitable applicants. Given the need for more posts in the community, there is now discussion as to whether general practice and palliative medicine can come together to provide joint training, an option that has proved popular for general practice and public health. I ask the Government to actively support these and other initiatives to free up the mobility of trainees, increasing their ability to move between different disciplines and places and their sense of belonging to a team. This is essential for maintaining more care in the community, which is outlined in the 10-year plan. I turn now to emergency medicine, routes into which are through the two-year acute care common stem, which allows trainees to train towards anaesthetics, acute medicine, emergency medicine or intensive care. At the end of the two years, they have to reapply for senior training, as there are very few run-through posts. The advantages are that they have a broad experience and can switch from one line to another, having had a common stem, but the reality is that recruitment is highly competitive. Many newly registered doctors are locally employed, which means that they are not in training posts but are doing very responsible jobs. In the London area alone, one trust that I know had more than 800 applicants for a small number of emergency medicine training posts. The bottlenecks are at every point in the system. This is another speciality where over 60% are now seeking less than full-time training, which is understandable given the stresses of the job and the difficulties of childcare commitments and so on. But if, for example, you have five training posts, and five trainees working at 0.8, which is equivalent to four whole-time posts, currently you cannot appoint a sixth person to the remaining one whole-time equivalent because of the shortfall in additional top-up funding for oncosts and so on. That means that we are chronically underreplacing, even in those disciplines where the fill rates are high. There is another problem. Training numbers are not evenly distributed fairly within the system and around the country. They need to be determined by population need, set as a formula. It is not appropriate for the south-east to have many more training posts than other parts of the country, such as under-doctored rural areas. Geography is an important consideration for many trainees. They often want to stay near the area where they trained in medicine. That is helpful because they have all the contacts to seek informal advice and support, but the targets to get through a certain number of patients can work against the system and the allocation of training posts. For example, pathologists and radiologists are essential to diagnostic processes but they may not feature in the target minds of many planners. The movement of finances can underpin the workforce and it is essential that we do this if we are to have our own graduates and know all aspects and the standard of their training, and if they are to be able to work and pursue careers in this country rather than be driven abroad, pulled by the attractiveness of recruitment programmes from Australia and other places. We trained them, and we need to harness all their potential.

14:18:00

My Lords, it is a great pleasure to follow my noble friend Lady Finlay and to thank the noble Lord, Lord Lansley, for the very thoughtful way in which he introduced this debate. In so doing, I remind noble Lords of my own registered interest as chairman of King’s Health Partners. As the noble Lord, Lord Lansley, said, there is a continuum here—a continuum from establishing the number of places that we have at medical school through to the foundation years, where those newly qualified medical students are able to hone and consolidate their skills, and then subsequently to choose to go into core and speciality training and ultimately seek permanent consultant or GP posts. It is fundamental to the process of planning that each part of that continuum is properly joined up. For instance, how do His Majesty’s Government deal with the question of ensuring that medical schools have an appropriate curriculum that is sufficiently flexible and will meet not only the training needs in the subsequent seven to 10 years after qualification of a medical student but the subsequent 30-odd years of clinical practice? In terms of expectations, how do we set the appropriate expectation for those bright young individuals, as the noble Lord, Lord Lansley, said, going to medical school, so they are better able to understand what clinical practice in future will mean? For a large number of them, with the Government’s determination that care is moved closer to home and into the community, the skills will include the capacity to apply digital technology and to be substantially literate in the use of data, as well as to be able to lead multidisciplinary teams, in addition to having a good understanding of pathophysiology, physiology, biochemistry and other clinical skills. Once individuals enter their foundation years, we must be clear about what core skills we need to consolidate that will provide them with the ability to adapt over a lifetime of clinical practice—and so too into core and specialty training. It is quite shocking that, in 2022, for those entering their subsequent training in 2023, the General Medical Council assessed that some 75% of those completing their second foundation year did not go into a core or specialty training post. Where did they go? Some of them clearly became locally employed doctors, but it is clear that the majority of those who have gone through medical school and had their early post-qualification training are not going immediately into subsequent training. Why is that? What do we have to do to make that subsequent core and speciality training more effective and agreeable for those who need to commit themselves to it? If they are going into locally employed doctor positions, professional positions where they are locally employed by trusts, principally to deliver service, is there a way we can provide the opportunity for those locally employed doctors to undergo some form of training as well? There is a substantial financial commitment to their employment and, given that commitment, which probably concerns at least half of the recently qualified workforce in the NHS, there should be an opportunity for training to be provided under those circumstances—as the noble Lord said, ultimately, potentially, to move to a portfolio system, whereby elements of that clinical practice, supervised and attended by training, could contribute to certification that could ultimately contribute to a pathway of accumulating experience, not only in core and specialty training posts with a number but through those locally employed doctor posts, increasing the amount of flexibility available. Beyond that, we have to consider how we do workforce planning. The previous Government, quite rightly, in 2023 was congratulated for having agreed and settled a workforce plan with substantial ambition in increasing the number of medical school and nursing places as well as in training more clinicians, based on what I assume was a determination of the changing population demographic and therefore a greater need for doctors in certain specialties and disciplines. With their 10-year plan, the Government have indicated that the workforce plan of 2023 is to be put aside. That, I think, is quite a problem. One of the things we need to be able to achieve in our country is a degree of consensus so that planning can be constructed and delivered over an extended period. What will be the new methodology? The 10-year plan indicates that the previous plan needs to be put to one side because we will have new models of care. We are going to be adopting digital technology and working in different clinical environments. That is all absolutely fine, but how is that to be modelled? What is the methodology? What is the certainty that we are applying the correct parameters to any modelling plan to allow us to determine which specialties and disciplines need to be expanded? Where are the geographical locations where this training should take place? What are the preferences of those who have gone to medical school and completed the early part of their training in terms of taking up such opportunities? In coming forward with the 10-year workforce plan, the Government are going to have to be very clear on these questions, so that whatever is proposed is plausible. My noble friend Lady Finlay raised the question of clinical academics. These are a vital part of the medical workforce. The Government are absolutely committed to innovation and its adoption at pace and scale across entire health economies, but at the very genesis of that innovation are clinical academics, and we have seen an erosion of clinical academics in the National Health Service over the last 10 to 15 years, with great problems in being able to ensure that those who choose an academic, potentially research-driven commitment, as well as a proper clinical commitment, can achieve training for both those elements side by side and still be able to compete for consultant posts after that. How do the Government propose to address that issue? Finally, I come back to locally employed doctors. It is critical that that large number of young clinicians are able to continue their early post-qualification clinical practice in a way where they remain strongly motivated and potentially determined to apply subsequently for core and speciality training posts. At the very least, they should continue to be developed in a supportive and meaningful way, so that they are fully flexible and have the capacity to make the important contribution that the health service over the coming years is going to require from all employees.

14:28:00

My Lords, we are all grateful to the noble Lord, Lord Lansley, for securing this debate and, as he said, it is an important issue that has been of concern for some years. It is important for our NHS and for the long-term health and well-being of our nation. We know that, in recent years, the competition for specialty training places has kept rising. There were over 33,000 applications for specialty training in 2025, compared with less than 20,000 in 2019. There are particular problems with some specialisms. In 2024, there were 112 applicants per post for general practice and public health medicine. This shows that there has been a serious breakdown in workforce planning to date. Parties have been ambitious in their manifestos, but not always in the planning and the execution. At the last general election, the Conservative Party expressed the desire to recruit 28,000 more doctors in the NHS than we had in 2023, and to do so by the end of this Parliament. But in government, they did not will the means to enable that to happen in that timescale. Medical school numbers increased by one-third between 2014 and 2024, but specialty training places increased by less than 10% in the same period. This disparity has created a severe bottleneck, leaving thousands of doctors who have completed their foundational training stuck outside the speciality training pathway and facing potential unemployment or having either to go abroad or to accept insecure roles as locally employed doctors. The General Medical Council observes that, of course, doctors not in training posts have a higher rate of leaving the profession, thereby exacerbating our retention crisis. Several factors have contributed to this untenable situation: there has been a stagnation in the funding for training places; there has been a lack of funding from Health Education England for training places, which is exacerbating the problem of competition ratios in specialty training; and the career progression of medical graduates has been impeded, leading to questions arising around the quality of patient care. The Royal College of Physicians has emphasised that increased medical school places must be accompanied by a plan to increase specialist training provision. It is illogical for us to invest in initial medical training, then deny thousands of UK doctors the opportunity to advance to specialty level. There is also the problem that training places are generally distributed based on historical arrangements rather than current population needs. The evidence suggests that trainees often remain in the area where they complete their specialist training, meaning an inequitable distribution of posts, which contributes to disparities in doctor numbers across the country. Health Education England and NHS England have a commendable programme called Addressing Health Inequalities: Distribution of Medical Specialty Training, which seeks to distribute places more equitably, but they must ensure that this leads to an overall increase in training places rather than merely redistributing existing capacity. The challenges in general practice training are particularly acute. The ambition to increase GP training places to 6,000 by 2031 is welcome, but the current pace of increase is not meeting the need and prospective GPs are being turned away. The current competition ratio of 3.67 applicants per post is too high. General practice is often perceived as less prestigious and GPs’ practices face immense pressures, making it difficult for senior GPs to dedicate the time and resources needed to supervision and training. I am sure that we will shortly hear more about the Government’s 10-year plan for the NHS to “tackle bottlenecks in medical training pathways” and, “over the next 3 years, create 1,000 new specialty training posts”. We know that Professor Sir Stephen Powis and Professor Sir Chris Whitty are overseeing a medical training review, but the NHS is unlikely to achieve what is needed for medical training without a clear costed plan for the NHS overall, which must involve properly addressing the social care crisis. Unless we tackle social care, we cannot tackle the problems of the NHS. The noble Baroness, Lady Casey, was charged with reviewing social care by the Government elected in July last year, but she did not begin this role until the end of April this year and her initial report is not due until two years after the general election, suggesting that plans for conducting such a review were not made in advance of the election. Her final report is not due until 2028, some four years after the general election, suggesting, again, that much more long grass may be involved on the issue of social care. It is 26 years since the royal commission on long-term care, 14 years since the Dilnot commission and six years since Boris Johnson’s pledge to “fix the crisis in social care once and for all”. Bookshelves are full of reports such as these. In the meantime, hospital beds continue to be occupied by people who should be in care but lack somewhere to go or people to look after them. There is an immediate crisis for community equipment providers, who provide much of what is needed to support disabled people. Their business model may face imminent collapse because local authorities cannot afford to pay them, cannot pay them promptly enough or—as in at least one case—are simply refusing to pay. There is much to do. We need a comprehensive, fully funded workforce plan that genuinely addresses the current shortfalls and the projected needs. This plan must be ambitious, adequately funded and published urgently. The current situation, where thousands of doctors are finishing their foundation programme only to find themselves unable to secure a training post, represents a cliff edge. This impacts doctors’ morale, potentially leading more towards the industrial action that we seek to avoid, more migration of medical talent and further harm to patient care. The commitment to increasing medical school places must be matched by an equal commitment to expanding postgraduate training capacity, ensuring that every doctor we train has a clear and secure pathway to becoming the consultant or GP of the future.

14:36:00

My Lords, first, I should declare my interests. We are not allowed any more just to say, “I refer my interests as in the register”. Very quickly, I am a professor of politics at St Mary’s University, Twickenham, and I am helping that university set up its medical school at the moment. It wants to tackle some of the issues, becoming an innovative medical school looking at technology and AI, but also at doctors becoming entrepreneurs in their own right. I also teach at the Vinson Centre at the University of Buckingham and, in those seminars, I invite people to come and speak on the future of healthcare. I have worked in the past with the Institute for Economic Affairs, have written on healthcare, and Buckingham itself has a medical school. I hope I have covered all that now. Having taken that one long minute to declare my interests, I thank my noble friend Lord Lansley for securing this debate and for sharing his experience and concern about the complex environment faced by foundation medical schools seeking to provide specialist training posts in the UK. Indeed, on entering the Chamber today, the noble Baroness, Lady Finlay, said to my noble friend and I, “It’s complicated”, and I think this debate shows that it is. In the UK, we are proud to boast some of the world’s leading universities in medicine and science. During the Covid-19 pandemic, the nation watched with admiration as our brilliant scientists and medical experts led the UK in becoming, if not the first, one of the first countries to roll out an approved Covid-19 vaccine. This reflects not only the dedication of our scientific community and excellent research facilities but the effectiveness of well-designed systems and our huge medical experience, some of which has been on display in this Room today. The noble Lord, Lord Kakkar, spoke of the continuum in medical training. After graduating from medical school in the UK, graduates enter the NHS’s two-year foundation programme, where they are exposed to a variety of medical specialties. Following this, they are supposed to embark on specialty training. However, as many noble Lords have pointed out, in recent years, UK-trained medical graduates have struggled to secure a speciality training post. Recent Answers to Written Parliamentary Questions asked by my noble friend Lord Howe and I reveal the scale of the problem. In 2024, there was only one medical oncology specialist training post in the north-east training region. For paediatric training, at stages 3 and 4, in 2024 there was again only one space available in the north-east and two in the West Midlands. Furthermore, in 2024 there were 14,104 foundation programme training places in England, but only 7,929 level 1 speciality medical training posts, meaning that there were almost half the number of speciality posts available for those in foundation training. If we look at the competition for postgraduate places, as other noble Lords have said, there has been an increase in the ratio from 1.9 applications per place in 2019 to nearly five applications per place in 2024. As my noble friend Lord Lansley said, it has been suggested that this is partly due to international medical graduates being able to apply under the same conditions as doctors in the UK. As someone who teaches in UK universities, I believe our education system benefits from foreign students. They are good for the UK’s soft power, the health systems in the countries these trainees come from and return to, or even places our British trainees go to. I believe we should continue to train world-leading doctors. If the problem identified by my noble friend Lord Lansley is left unaddressed, it could lead to a transformation in the make-up of our doctors and a decline in opportunities for British graduates. As the noble Baroness, Lady Finlay, said, it is welcome that priority is being given by this government to UK students. In light of this, may I ask the Minister what action the Government are taking to increase the number of speciality posts available and to fill some of the vacancies referred to by the noble Baroness, Lady Finlay? I have to admit that I have heard from some doctors I met during my time as a Minister, and now as a shadow Minister, that we should focus less on specialism and that we want more people to go into general practice. But the noble Lord, Lord Rennard, just pointed out that there is a bottleneck in GP training. The noble Lord was also absolutely right that social care has to be taken care of. At this point, I should like to divert slightly, because the late Lord Lipsey and I were working on a cross-party solution to fund social care, but he sadly passed away recently. On behalf of everyone, I pay tribute to Lord Lipsey. I did tell him when he was ill that I would work with another Labour Peer to make sure that we work on a cross-party solution. As the noble Lord, Lord Kakkar, said, under the previous Conservative Government, former Prime Minister Rishi Sunak unveiled the NHS Long Term Workforce Plan. At the time it was called the most ambitious transformation of NHS staffing in its history. As with any plan, there were critics, but the plan aimed to double medical school places to 15,000 by 2031 and to train 24,000 more nurses and midwives, reducing the reliance on international recruitment by cutting agency spending. Now that the Government have launched their 10-year plan for healthcare, there are obviously many questions on how this will be delivered and the implications for the workforce. We have heard how the new Government will put aside the previous plan and will produce their own 10-year workforce plan later this year. My noble friend Lord Lansley referred to some of the commitments in the recently published 10-year plan and the noble Lord, Lord Kakkar, rightly raised some fundamental questions that need to be answered. Can the Minister enlighten the Grand Committee on some of the aspects that will be included in that 10-year workforce plan? I know the noble Baroness may have to say that she cannot jump ahead or reveal details, or that it is still being worked on, but could she say whether there are some broad issues that will be tackled at the high level, without necessarily giving numbers? I understand that it is always a challenge to ask a Minister about specific issues in advance of a plan. Although foreign students are good for our education system, can the Minister clarify what more specific actions will be taken to ensure that there are more opportunities for new UK medical graduates. We should be clear that this is not an anti-foreigner sentiment at all. It is good that we can train people from all around the world—good for our universities, our economy and the countries they will go to. As a country, we will benefit from this in the future, but there are some fundamental questions that all noble Lords have asked. I know the noble Baroness may not be able to answer all of them at the moment, but it is critical that we address these crucial bottlenecks and understand how we can ensure that, while we want to see more students trained and new medical schools may be opening, including the one I am helping with at St Mary’s University in Twickenham, we make sure there are opportunities—to tackle not only the bottleneck but the other side of that bottleneck. Then we can make sure that those trainees, whether British or otherwise, can go on to deliver world-class care in our National Health Service and beyond.

My Lords, I apologise to the Committee; I should have declared my interests. I am an observer on the Medical Schools Council, I chair the Bevan Commission in Wales and I hold the chair at Cardiff University.

14:44:00

My Lords, I thank the noble Lord, Lord Lansley, for instigating this debate and the noble Baroness, Lady Finlay, and noble Lords for their contributions. We have had a rich discussion. I will not be able to answer all the points raised, as I am sure noble Lords are aware, but this is extremely topical and essential to determining the way forward through the 10-year plan and the workforce plan, as noble Lords have referred to. To pick up on what the noble Baroness, Lady Finlay, said, at a time when morale is quite low across the piece, for reasons we do not need to go into now, focusing on how we harness potential and make entry into these professions fit for purpose, exciting and rewarding must be at the heart of everything we do. We must be honest that the Government have inherited a system where competition for specialty training posts has grown significantly in recent years. In 2024, there were 4.7 applications per training post, an increase from 2.4 in 2020. That is a significant change. We recognise the frustration this has caused resident doctors and that their career progression is becoming a lot more complicated. I reassure the noble Lord, Lord Lansley, that we are committed to tackling this. There are multiple reasons why competition ratios have grown. As a result of changes to the Immigration Rules in 2020, international graduates have been able to apply on equal terms with domestic graduates. We are also seeing more people graduate from UK medical schools, as we have heard. More domestic graduates are entering training, a number of private medical schools have opened and some UK universities now run medical courses at overseas campuses. All this creates a perfect storm. Like the noble Lord, Lord Lansley, we welcome the increase in the number of graduates, but we need to work on managing the process of dealing with it. As a Government, we have consistently acknowledged the concerns of resident doctors and are actively working to address them. As set out in the 10 Year Health Plan for England published on 3 July, we recognise that we need to work across government to prioritise UK medical graduates for foundation training. We will also prioritise UK medical graduates and other doctors who have worked in the NHS for a significant period for specialty training. We recognise that internationally trained staff remain an important part of the workforce, but there is an explicit understanding that we have become overreliant on them and must address this, as the noble Baroness, Lady Finlay, mentioned. We are aware of the concerns about specialty places, particularly in certain specialties. Without doubt, the NHS and universities must do more to get doctors into the specialties where the NHS and patients—we must remember patients’ needs throughout this—need them. As I said, the Government will address this head-on. As the noble Baroness, Lady Finlay, mentioned, the flow of this is critical. To respond to the noble Lord, Lord Rennard, our 10-year health plan commits to creating 1,000 new specialty training posts over the next three years, with a focus on specialties where there is greatest need. I will have to write to the noble Lord, Lord Lansley, on his point about this. We cannot make specific geographic commitments, but we recognise that this is an issue. That is why the 10-year plan focuses on neighbourhood planning, bringing together all the experts in an area. The 10-year workforce plan will be published later this year to create a workforce ready to deliver a transformed service. This is becoming a bit repetitive, but I have to say to the noble Lord, Lord Kamall, that I cannot pre-empt the outcome of that work. However, it is significant. We recognise the comments on bottlenecks and emergency medicine and the comments of the noble Lord, Lord Kakkar, on locally employed doctors—a fundamental part of the picture—and the need for clarity. That absolutely runs through the work we are doing. So the workforce will be more empowered, more flexible and more fulfilled. The whole basis running through the 10-year workforce plan is to ensure that the NHS has the right people in the right places with the right skills to care for patients when they need it. I emphasise to the noble Lord, Lord Rennard, that social care runs through this. We absolutely recognise that it is critical that we deal with this. We want to make sure that the noble Baroness, Lady Casey, is allowed to get on with the work. She is committed to working cross-party and bringing all the experts together to tackle this. I did not know about the work that the noble Lord, Lord Kamall, was doing with Lord Lipsey, and I am grateful for his comments. The noble Lord, Lord Kakkar, asked about how this will be done. It is a huge amount of work, and he is absolutely right to focus on how it will be done. The important thing is that we are asking the question. Given our reform plan, what workforce do we need? What should they do? Where should they be deployed? What skills should they have? This is reflected in the three shifts in the 10-year plan. We will use a range of methods to determine this, including traditional modelling, of course, and in discussion with those who deliver these services, local system leaders and planners, higher education institutions, which are absolutely critical in this, and, of course, the royal colleges. It is critical that our whole workforce is fit for the future, and we are determined to make that happen. Interesting comments were made about a portfolio approach. The medical training review was launched in February, the consultation has come back in and we are looking forward to the report. The Government have also committed to training thousands of new GPs. Perhaps I should have declared that my son is a GP—he got through—so I have had some personal experience in this area. It is important that we all pool our collective experience. We are committed to training thousands of new GPs and are already well on the way, having recruited an additional 1,900, and there will be an additional 250 later this year. But it is critical that we then address how they will be employed in the current estate, for example. That of course is addressed in the 10-year plan. I want to reassure all noble Lords who mentioned concern about clinical academic roles. We will reverse the decline through a collaboration between the Government and major charity funders. The collaboration will fund a year-on-year increase in these roles over the next five years. We are also encouraging additional funders to support clinical future leader fellowships as the scheme develops. We agree that this needs to be a co-produced piece of work across the patch. As I said, the Government understand the high level of competition. It comes at a time when many doctors are already feeling unhappy with their experience in work and in training. That is why we have laid out the 10-year health plan and the 10-year workforce plan, working together to address these issues. We have been listening to doctors to make their working lives better. There is much more to do, but the NHS has been making good progress. We want our trainees to stay in this country. We recognise that a number of them go abroad, but many of them come back. We need to be very careful when we analyse the statistics in front of us. We are making progress with the improved exception reporting system, for example, reviewing rotational working and reducing mandatory training, which has been something of a nightmare. NHS England is also delivering the retention programme, working with trusts so they better understand why staff have left. I thank noble Lords again for their time today. I know it is frustrating at this moment not to be able to answer all the specific questions, but I hope all noble Lords will recognise the significant pieces of work going on—

Just to return to a point I mentioned about supporting professional activities as part of consultant job plans, I think it would be very helpful if the Minister would say that, notwithstanding the prioritisation of delivering on things such as waiting list targets, consultant job plans must make provision in their contracts for them to commit their time to training activity.

I would be surprised if that was not already under consideration and, when the pieces that have been out to consultation come back in, I would expect that that would be part of the consideration. I certainly recognise the significance of the noble Lord’s comments. I just want to reinforce that, as well as being in delivery mode, the Government are in listening mode. Over too many years, there has not been enough listening and enough recognising that people out there in the workplace have a lot of the solutions to some of the problems we are facing. It is complex and challenging, but the prize at the end of this work is well worth striving for and I look forward to updating noble Lords as we go forward.

14:57:00

Sitting suspended.