In this issue
Competition ratios · Surgical robots · Family wealth · Board Round · Second Opinion · Take‑Home

Some narratives that the 2026 ratios hide

The annual competition ratios are out and it’s the first look at how the UK graduate prioritisation legislation influenced applications and behaviour. In order to pull the best narratives from the data we can’t look at the competition ratios alone; we also need to compare them to NHS England’s prioritisation spreadsheet. You are in luck, because that’s exactly what we have done for you.

So what narratives can we take…

The Act was brought about as an antidote to the spiralling and unsustainable competition ratios and aimed to bring these ratios down by prioritising home graduates. In terms of achieving that goal, it did it to dramatic effect.

Of the 19,479 applicants who fell outside of the priority group, just 427 accepted a post. That is just 2.2% of them, and 4% of all posts. Last year, 28% of all posts went to non-priority doctors. Of these 427 posts, the majority were in Internal Medicine Training.

We say “sort of” because 9,700 priority applicants still ended up with no post. 19,908 priority applicants applied and 10,242 accepted a post.

At this stage it’s also probably worth clearing up some confusion we are seeing online. “Priority” doesn’t mean UK graduate. In fact only 73% of posts went to UK graduates; in GP this number was 65%. Credit to GP, it is giving us the most surprising narratives. So here’s one more: did you know that GP alone took 84% of all British citizens with foreign degrees?

You don’t need to be Terence Tao to see that the Act changed the landscape of successful applicants massively. Some standouts remain: 70% of psychiatry applications came from people who the law put at the back of the queue, and for UK graduates, GP entry was close to guaranteed with a ratio of 1.3.

It turns out the biggest loophole in UK medical legislation is a willingness to move to Belfast. Geography allowed those in the non-priority group to get around the Act. If these doctors were prepared to rank regions in the country that had fewer priority applicants listing them, they stood a chance of taking up posts in them. Northern Ireland has 71 IMT posts; 35 of them (49%) went to non-priority applicants. Compare that to 13% in England and 0% in Scotland.

Time to humble the surgeons a bit as well. There were 13 unfilled posts in the entire round and all of them were CST posts in England. No doubt someone out there is trying to see how they can blame an anaesthetist for this.

In psychiatry, 7,528 applicants were deemed “appointable”, i.e. they had achieved the minimum standard of competency that the speciality accepts from successful applicants. Take it as recruitment’s version of “it’s not you, it’s me.”

That doesn’t mean you have a post though, as you are competing against 7,527 other appointable candidates for 552 posts. Interestingly, 5,973 of those appointable candidates came from those in the ‘non-priority group’.

Compare this to anaesthetics, which had 1,733 non-priority applications, but only 10 were appointable.

What explains this? Well, the answer would seem to lie in the selection process. We’ve written about this at length in previous editions of On-Call, but psychiatry solely relies on the MSRA for appointability, whereas anaesthetics has a heavy weighting on the interview after reaching an MSRA cut-off score.

NHS England is desperate to get people into general practice posts. For a UK graduate, a post was close to guaranteed.

Many readers won’t know that, compared with last year, total posts across all specialities rose by about 1,000. GP took 788 of them. That means nearly 80% of all new posts created this year were in general practice. Specialities where we know from censuses that we have a huge shortage of consultants, like radiology, shrank from 356 posts to 327.

We are of the opinion that a robot is unlikely to do your endarterectomy or tonsillectomy unsupervised any time soon. But it’s worth asking why. Why do we seem to be safe (for now)?

AI has taken off wherever there is data, and lots of it. Pathology has endless slides, each with a report attached. Surgery has no obvious equivalent. da Vinci robots record their every movement (yes, really), but most operations are still done without a robot, and laparoscopic videos are not stored.

We await the day a morally questionable corporation offers a hospital £10 million to strap GoPros to its consultants to acquire operative data sets. Even then, video alone probably isn’t enough. Someone would need to explain what’s in the field of view, and anyone who has asked a consultant mid-case “what’s that?” knows how that conversation goes. But it’s not impossible.

Things also go wrong in real time and surgeons improvise, or so they tell us. Robots, so far, can’t. When a vessel unexpectedly blows, you might as well push the robot aside and call the anaesthetist over to have a go.

Having said that, we are seeing some signs that robotics is slowly making marginal gains. In 2022, the STAR robot successfully performed a bowel anastomosis on four live pigs. They examined the tissues a week later for bowel leaks (and other things that can go wrong with a bowel) and the results were comparable to those achieved by human surgeons.

So yes, the technology should be on our radar, but it seems a long way from theatres at the moment.

Follow your passion (unless you can’t afford to)

There was a recent discussion on the r/doctorsUK subreddit from a second-year radiology consultant who had attended a medical school reunion. He was refreshingly honest about what drove his own career decisions: financial instability when growing up. So here’s the question: how much does family wealth impact the career choices that we make?

We have long known that socioeconomic background can shape who enters medicine. But what does the evidence tell us about how socioeconomic background can impact how we navigate training?

So the hypothesis goes: medics enter training with unequal financial resources and tolerance for financial risk. These differences can influence the career paths they go down.

So does the evidence support this?

A 2019 paper examined 6,065 UK doctors who entered speciality training after completing the foundation programme between 2012 and 2014. They found those whose parents had not attended university had a lower likelihood of entering a medical speciality rather than general practice.

Surgical training is commonly known to be a minefield, a speciality where post-CCT fellowships, additional higher degrees and extended years out of training are becoming the norm. A 2017 paper from the BMJ found that doctors who attended an independent school had higher odds of training in surgical specialities.

So we have some quantitative data. Some of you may be saying ‘of course wealth gives you greater opportunities, through better education, better networks, ability to attend conferences, pay for higher degrees’. But we think there’s a more important variable at play here:

Wealth changes the urgency with which one needs to earn money.

If a doctor has little family wealth and no meaningful financial safety net, the years spent training on a lower salary have a real opportunity cost. By contrast, if you know that you have a substantial financial safety net, your financial security might be partly assured. You can afford to prioritise your intellectual interests, prestige, academic medicine or simply enjoy your twenties.

For some, every additional year before reaching a consultant salary has a real opportunity cost in forgone earnings. And it seems that this cost is more consequential when you have no family safety net.

We are in the era of the ‘Great Wealth Transfer’. Over the next three decades, about £5.5 trillion is expected to change hands from Britain’s baby boomers who were brought up in a world of growth. And this distribution is going to be far from equal. We can no longer ignore the fact that the distribution of this wealth will affect the specialities that we choose.

“Every handover has one sentence that ruins your evening, and it’s always ‘just one more thing, it’s probably nothing’. It’s never nothing”

“Consultant on the ward round: ‘Any questions?’ Silence. Consultant leaves. Forty-seven questions and requests for me, the F1, to look into.”

“From hanging around online forums, I am of the opinion that medics grossly overestimate how easy it is to become, say, a partner at a big financial firm. When they compare earnings, it seems some people believe that any medic would find themselves at the top of the consulting, finance or corporate law world. Cherry-picking from top firms and comparing their salaries to those of a consultant is an intellectually weak argument. This is why we have averages, and averages tell us that when lifetime earnings are assessed, medical graduates come out on top.”

“Let’s be serious now. General practice describes the role of a GP far better than ‘family medicine’.”

What’s on your mind? Email us!

Talk about consultant private practice earnings has surfaced following the BMA’s strike action. In reality, the last robust study we had was from HMRC tax returns in 2003/4. This showed the mean private income across all consultants was £34,144. That is around £70,073 in today’s money. It also ranged massively between specialities, from paediatric neurology earnings of £5,144 (£10,516 in today’s money) to £142,723 in plastic surgery (£292,913 in today’s money).

The Institute for Fiscal Studies has released a great document outlining what options we have when addressing the problems associated with Plan 2 student loans. It’s 30 pages, but luckily there’s a key findings section at the beginning for you to read.

Last week’s poll:

Taking into account all the potential benefits and negative consequences, would you make general practice training five years tomorrow?

…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!

Common finance advice tells people to avoid overpaying their loan. “Pointless,” they say. But for a full-time doctor, the maths is very different from the average person, who wouldn’t get close to clearing off their full loan.

£10k paid in April 2027 on a £100k balance cuts lifetime outgoings by £26,300 and clears the loan two years earlier. Consider that we talk so much about generating more interest on our savings here and investments there. This is a guaranteed return of about 6.3% a year, risk-free.

That said, there are clearly examples when you should be careful before deciding to overpay. If you work less than full time in your career, emigrate or leave medicine entirely (to a lower-paying job where the likelihood of paying off your full loan decreases), you can’t write to the Student Loans Company and ask for your money back. You need to be confident that you will have paid off your full loan by 2057 before you make the decision.

One more consideration. The injustice of the student loan system is finally starting to gain traction in the media. The Times has an entire campaign dedicated to it, titled ‘End the Graduate Rip-Off’. The IFS is regularly publishing analysis on the subject. Senior politicians are increasingly being forced to answer questions on the issue. There are even those who believe some form of loan forgiveness is a serious possibility.

Now, if you happen to pay off a substantial portion of your loan before such a policy is introduced, we wouldn’t count on getting that money back.