Competition Time: What to Make of the New Speciality Training Ratios

Some On-Call thoughts on the new speciality training application data

The numbers don’t look too good, do they? Competition ratios continue to haunt doctors, whilst on-call, at dinner and probably in their sleep. Every year seems to provide fresh evidence that things are worsening, with 2025 being no exception.

The headline figures suggest that a total of 91,999 applications were made in England for 12,833 speciality training posts, translating to an average competition ratio of 7:1. Just a year ago the ratio stood at 4.7:1, and only six years ago in 2019 it was 1.9:1. Averages also hide extremes; In psychiatry, for example, 10,677 applicants competed for just 489 posts.

Clearly, this level of increase cannot be sustained. It raises the obvious question: What will the ratios look like in another two or three years? No one wants to be accused of the ‘Linear projection fallacy’ (look it up), but things are not looking good.

The solutions are limited: either reduce the number of applicants, or increase the number of training posts. Both options are being debated amongst those responsible for health policy. Wes Streeting has promised 1,000 extra posts over the next three years, while discussions about prioritising UK graduates continue to resurface.

At On-Call, we unfortunately don’t have the perfect policy fix. But we do want to share some of our thoughts on the data.

Show Me The Numbers

As per Health Education England’s own 2024 numbers, 71.4% of all ST1 applicants were International Medical Graduates (IMGs), 6.9% EU doctors and 64.5% were from the rest of the world,. As the EU doctors group made up the smallest number of applicants with just 6.9%, we will put their data aside for a moment, but their figures are linked above. So for the sake of simplicity, in the rest of the article, we will refer to the ‘rest of the world’ doctors as IMGs.

Among the 43,755 IMG applicants, 10.4% secured an offer, compared with 48.8% of applying UK graduates. Around a third of these UK graduates receiving offers later withdrew their applications (because doctors applied to multiple specialties, changed their minds, or had location issues), but the point stands: while competition is rising, it is simply not true that UK graduates face minuscule or a ‘one percent chance’ of getting a post, as some circles may suggest. The data shows the odds are far better than that.

The IMT Outlier

As our IMG community may already know, Internal Medicine Training (IMT) is the most popular hospital specialty for IMGs, and the data here looks very different. 20.4% of applicants were successful, nearly double the overall IMG average of 10.4%. For UK graduates, the success rate sat just above the 48.8% average, at 51.2%.

Why? Many believe the explanation lies in the MSRA exam. Unlike other specialties, IMT does not use the MSRA, which is thought to be protective for UK graduates, particularly the Situational Judgement section, which reflects principles taught heavily in UK medical schools and through the foundation programme.

To strengthen our SJT argument, the contrast is striking when we look at anaesthetics which opts for a combination of MSRA and Interview. Of the 2,880 IMG doctors who applied, only 17 were offered posts (0.6%).

Yes, we know budding ophthalmologists will lament learning about paediatric vaccine schedules, but if you are one of our UK graduate readers, then the exam does, in practice, tilt the odds in your favour.

The Ever-Rising Portfolio Ceiling

It’s no secret that UK graduates tend to perform better at interview than IMGs, often due to language fluency and NHS experience. But as applicant numbers rise, the threshold for even reaching interview will continue to climb.

That means UK graduates are under pressure to start building portfolios earlier, sometimes from medical school, to remain competitive. Meanwhile, IMGs often bring years of additional experience, postgraduate qualifications, or even PhDs, which raise the bar further.

Some may question what the issue is here, using arguments that suggest the most qualified candidate should get the post. But like most questions surrounding this topic it always comes back to the same question: Does the state have a fundamental duty to protect and favour its own workforce, given the significant taxpayer investment in training doctors domestically?

Without This, The NHS Collapses

Free speech… It’s been making the headlines in recent weeks. We deeply value it, because we understand that it is only in an environment where a plurality of ideas are able to compete against one another, without fear of persecution, that noble and valuable opinions rise to the top.

But for doctors, the issue is often more complex, because what we say can be interpreted by some as representative of the profession. So the question for us becomes: What are we actually allowed to say?

We all know there has to be some curtailment of freedom of speech for the smooth functioning of society, but how much is ‘some’ has always been a challenge to pin down. The famous analogy of a person shouting ‘FIRE!’ in a crowded theatre shows that free speech should never be absolute. In a similar light, whenever the speech of a doctor strays into harm or exploitation, it ceases to be ethically defensible. What constitutes speech causing harm is the second more nuanced question that needs ongoing discussion.

Many don’t understand this: Trust is the foundation of the NHS and healthcare in general. Without it, medicine completely collapses into suspicion and inefficiency. Every prescription will be challenged and every diagnoses will be second-guessed. Clinics will run on for even longer than they already do. If doctors began spewing information that could easily be shown to be empirically incorrect or false, it becomes difficult to preserve the trust that allows medicine to function.

The Clinical Academia Crisis

Are the foundations of evidence-based medicine cracking?

There are some hard truths about the state of UK clinical academia. The 2024 Medical Schools Council census revealed that there are 3040 full time clinical academics in the UK. That equates to only 3.4 per cent of consultants, a sharp fall from 4.7 per cent in 2009, representing a near 30 per cent decline in relative terms over just 15 years.

What makes this even more troubling is the age profile. A third of current clinical academics are aged over 55 and nearly two-thirds of professors are approaching retirement. These problems aren’t unique to the UK either, with a similar decline in clinical academics seen in the US.

Most doctors may remember encountering clinical academics during medical school in the lectures that they actually decided to attend. They were the figures that were part doctor, part researcher, and part educator. The BMJ rightly called them the bridge between science and clinical medicine. They serve at least three essential functions through delivering basic sciences research, teaching at higher institutions and leading clinical trials to evaluate the introduction of products into healthcare.

But whilst the NHS Long Term Workforce plan aims to double the number of medical school places by 2031/32, has any thought been put towards the need for clinical academics to cover the proportionate increase in medical school teaching requirements?

Something quite interesting, however, is that UKMED data shows that approximately half of fully qualified academic doctors do not progress into clinical academic work in UK medical schools. So the NHS is providing substantial funding to produce clinical academics but not retaining them. Either these individuals can’t find jobs in medical schools or they don’t want them.

Push and Pull

So why does the system fail to hold on to the very people it trains? Part of the explanation lies in how the academic pathway is perceived and structured. For a start, the recent shake-up of the Specialist Foundation Programme (SFP) did little to help. Two-thirds of SFP spaces were given out via the famous preference-informed allocation system (aka the random number generator), weakening the link between motivation and allocation and leaving many aspiring academics disillusioned with the system.

Add to this the competitiveness of Academic Clinical Fellowship (ACF) posts that are usually tied to specific geographic centres that offer limited flexibility for trainees with families or other commitments. Those who are lucky enough to find a post now encounter the ‘academic treadmill,’ where publications, presentations and grant applications must be repeated to sustain funding.

For many, whilst the pursuit of a PhD is noble and intellectually stimulating, they worry that the delayed progression to consultant pay and job security is not worth the time. This financial gap should not be overlooked, especially with the rising cost of living in the very cities where these prestigious academic centres lie (London, Oxford and Cambridge being the main culprits).

Foundation of Medicine

And yet, despite these obstacles, medicine cannot function without its academics. Not to sound dramatic, but they are the foundation of medicine. All those guidelines you act upon, the medications you prescribe, and the procedures you undertake are the product of a significant evidence base. We feel that in the eyes of many, clinical academia is treated as a luxury rather than a necessity. We hear the headlines around speciality training and consultant bottlenecks, but rarely the decline of the academic workforce.

Clinical academics are the people who ask the questions that move medicine forward. If we let them slip away, then we face a healthcare system with stagnating practice and ultimately poor patient outcomes.

“Trying to swallow my sad-looking sandwich between bleeps is my favourite sport of the day. Practically gave myself an upper airway foreign body as I was called to remove one”

“Artificial intelligence has the potential to create MORE work. Yes, more not less. If you have an oversensitive AI system which leads to over-diagnosis, then all you end up doing is increasing the workload through more scans and unnecessary procedures.”

“I was sat with an F1 colleague who said that she got dattixed (yes that is an NHS verb now) for missing a cannula - there is not a single day where this profession does not amaze me”

“Here I am again, asking for the FRCA and ST4 gods to let me reach the promised land”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

We’ve all made mistakes at work that required us to apologise and whether that apology had to be directed to the matron, a colleague or a patient, there are some powerful psychology tools that we can use to make our apologies stick. Read here to found out more.

Remember a time when the desire to ‘climb up the housing ladder’ was still a thing. Well analysts believe that is all changing with first-time buyers having to save until they are older to buy a home, this leads them to try and land that ‘forever-home’ first time, even if it means over-stretching themselves on a large mortgage. The On-Call team is well aware from speaking to our own doctor community that rising stamp duty costs significantly plays into these figures. Read the full story here from The Times.

Weekly Poll

Last week’s poll:

Be honest, have you ever been guilty of inflating your own CV, online or in-person?

…and whilst you’re here, can we please take a quick history from you?

Something you’d like to know in our next poll? Let us know!

The ‘AI-Triage Tool’ Ethical Dilemma

We know it’s the end of this weeks newsletter, but what better time for an ethical dilemma than as you’re about to leave?

It’s a busy January night in the Emergency Department, the Winter of 2032 has been one of the most arduous in memory. Despite the initial pushback, your trust has recently rolled out a new cutting edge AI triage system to cut waiting times. Early evaluations show it has reduced waiting times by 30% and improved overall survival rates by allowing the sickest patients to be seen promptly.

One particular night, the AI system triages a patient with abdominal pain and downgrades them, but the SHO disagrees. The patient looks unwell and, despite borderline normal observations, there’s something about their presentation troubling the SHO. He decides to flag his concerns to the consultant in charge, who is battling to address the six hour backlog of patients. The SHO is told to trust the AI as “it’s more accurate than any of us”.

It’s a difficult position for the SHO. He can either trust the AI algorithm which statistically outperforms human doctors, but risks missing rare, atypical presentations or override the AI using his clinical judgement, but risk potentially slowing down the system, delaying care for other patients and receiving a stern word from the consultant. So, would you prioritise the individual who might be the outlier, or the population who would benefit overall from AI efficiency?