Prioritising UK Graduates: The Comfortable Conversation We Need to Have

Are we shying away from talking about a key feature driving the specialty bottleneck crisis?

You would be hard-pressed to find any resident UK doctor who hasn’t gawked at the most recent speciality training competition ratios. At this point, it’s practically an obligatory sequence of events: open annual ratios, gasp, send a screenshot to the group chat, and say “it wasn’t like this in 2018”. The trend is unmistakable, but whilst the number of applications have been creeping up for some time, it is the last couple of years that have left everyone fearful of the future.

Applications are accelerating at a rate no system designed decades ago could have ever anticipated. In just three years, speciality training applications have risen by 67%, from 20,194 (2023) to 33,870 (2025). International applications alone have doubled, surging from 10,402 to 20,803 in the same period.

If we enjoyed a gamble here at On-Call, we’d put money on seeing record-breaking application numbers once again this cycle.

The Uncomfortable Question

The figures above bring us to an almighty question that often floats in the background but is almost never voiced with any sincerity.

Imagine, for a moment, that Wes Streeting is sitting across from you and asks, calmly, directly: “Two thousand extra training points weren’t enough. What number would make you genuinely satisfied?”

Most of us would struggle to offer an answer that feels honest. Suppose you bravely suggest with a straight face that Streeting should find his magic money tree and create 15,000-20,000 new posts, enough to theoretically accommodate every applicant. Even this impressive expansion would not resolve the underlying issue. It would temporarily relieve competition, yes, but given the rates of expansion, next year’s cohort, larger again, would simply reset the pressure.

It also risks creating a far more dramatic problem down the line: a consultant bottleneck of unprecedented scale, with a generation of highly trained specialists left waiting around. (click here to read why we think the prospect of a Consultant bottleneck is far more dangerous for the UK healthcare system.)

Beneath all of this lies a simple but deeply uncomfortable insight, one that makes perfect mathematical sense but is rarely discussed openly: if the system cannot expand training capacity at the same rate as applications, then the only viable mechanism to preserve the training system at large involves UK graduates being prioritised to prevent them from becoming a shrinking proportion of the country’s training schemes. This is not an ideological stance. It is basic workforce planning.

Cultural and Political Risk

Doctors, if anything, overanalyse trends. Most of them will be able to see that the accelerating number of applications is completely unsustainable. But the reason these topics are often avoided is a collision between professional culture and political risk.

Doctors, as a group, tend to avoid positions that create interpersonal friction. Research across high-conscientiousness professions shows a strong preference for solutions that produce no visible “losers”, which means policies involving prioritisation, exclusion criteria, or differential access feel emotionally hazardous, even when they are operationally necessary.

Layered on top is the political sensitivity surrounding anything remotely linked to immigration. No matter how carefully framed, any proposal that touches international recruitment is instantly swept into broader, more heated debates on nationality and immigration.

Most clinicians have no desire to be unwilling participants in a culture-war narrative, so the safest option becomes silence. But silence has consequences. Avoiding conversation entirely has consequences; we remove a legitimate policy tool from consideration through fear.

Tough Solutions

If the NHS is to remain both fair and functional, we will eventually need to have a grown-up conversation about how many trainees the UK can realistically support from medical school through to CCT. This includes whether medical school expansion should be legally tied to postgraduate capacity, and whether UK graduates should have guaranteed first access to UK-funded training pathways.

We are no strangers to why these topics may evoke discomfort here at On-Call, and in fact, discomfort may even be a useful moral urge to allow us to reflect and deliberate before reaching our conclusions, but discomfort has never been a reliable sign that a topic is unimportant. In fact, usually it is the opposite.

Is There a Case For a Second ‘Work’ Phone In The NHS?

A long week in the hospital finally ends, and you settle down by the fire, ready for whatever Friday night television can offer. Just as you begin to switch off, your phone lights up. One notification from Outlook asking for a form to be signed by your senior. Another from WhatsApp asking for cover for the Sunday twilight shift. Many doctors recognise this moment. This quiet erosion of our personal time with workplace commitments has become normalised in medicine.

Enter the debate around work phones for doctors as a way of establishing boundaries. Yes, you can mute group chats associated with work, but to what extent is this practical? Can one do the same with their emails and all forms of communication, including individuals who want to message us about work-related matters? A separate work phone would create a clear clinical channel and would reduce the risk of data breaches that come with using private messaging platforms.

But not all doctors will be willing to own another piece of tech to stuff into their scrub pockets, another item to potentially lose and an additional thing to remember in the morning. They may feel one phone is manageable, and the money needed for the scheme would be best invested elsewhere.

Has anyone considered that easier access to staff through a second ‘work’ phone might make out-of-hours contact even more enticing and frequent? Some make the slippery slope argument that the culture work phones could create isn’t one they want.

Is Jeremy Hunt After Your Pension?

“Guaranteed £125,000 a Year In Retirement” — Just Ignore the Small print

There’s a word that gets thrown around whenever economics comes up: fair. Not too long ago, Rachel Reeves floated the idea of reversing the triple lock pension, only to U-turn in the name of fairness. And fair economic policy is, of course, essential. But we all know saying the word “fair” isn’t the hard part; it’s agreeing on what it actually means.

Jeremy Hunt, ever the champion of NHS staff, popped up in the media again, apparently to defend doctors’ pensions…

Oh wait, my bad. He was actually writing to warn everyone about how unfair public sector pensions are.

According to Hunt, defined-benefit pensions that provide a pension guaranteed for life and, in our case, linked to inflation, are simply too generous compared to what private sector workers receive. We know that our pensions aren’t funded in the way private pots are, which are tucked away in personal pots. Our contributions are used to pay the pensions of current retirees. So in the NHS pension, liabilities are ultimately met by future taxpayers. This is no secret, and is how most public sector defined benefit schemes work.

We have said many times at On-Call that, for all the pressures, compromises and absurdities in this job, our NHS pension remains as one of the most meaningful long-term benefits of a medical career in the UK…

And that’s precisely why it has become an easy political target.

The Headline Built To Mislead?

The Times also wanted a piece of the act. They claimed that resident doctors “could get a guaranteed pension of £125,000 a year”. For most of the UK, that is an astronomical figure for a retired individual. If you wanted that level of income from a private pension over 25 years, you’d need a pot of roughly £3.1 million (125,000 × 25). So it’s no surprise that this headline created shockwaves online.

But the assumptions behind it? That’s where things get interesting and The Times have something to answer for. The figure, calculated by finance firm Quilter, relies on a scenario that (as NHS pension guru Dr Tony Goldstone has already pointed out) almost no doctor actually lives. The scenario assumes a doctor graduates at 23, passes every training hurdle the first time, becomes a consultant early, works full-time for 43 years with no breaks, and retires at the state pension age.

For a start, the average retirement age for medical staff is around 61. For GPs, many leave even earlier. Retiring before your “normal pension age” results in an actuarial reduction, meaning your pension is cut each year you take it early. Almost no one in UK medicine works full-time to 67.

Most doctors also know that this route to consultancy is a fantasy. Additional degrees, research time, rota gaps, training bottlenecks, burnout and LTFT for children or other reasons are not exceptions to the rule; they are becoming the general rule.

So, is £125,000 theoretically possible? Yes, it is, in the most optimistic, unbroken, best-case career path imaginable. But best-case scenarios do not make good headlines. A more accurate line would have been:

“Some doctors could reach as much as £125,000, but this is rare and requires a perfect career trajectory.”

Not quite as clickable is it? (Don’t even think about replying with an example of what you think is an On-Call ‘Clickbaity’ title)

Even Quilter’s own analysts conceded that while the NHS pension is “undeniably very valuable”, this value comes only after decades of long hours, intense responsibility, high cognitive load, antisocial schedules, and sustained service. One can only hope readers made it to that part of the article before clicking off at the title.

Why This Matters

The NHS pension is valuable, yes. No doubt about it. We don’t gain anything by downplaying the value of our pension. Valuable things are worth fighting for. If one sees something as worthless, then they shouldn’t complain when they are taken away.

But it’s the delayed repayment for years of training, responsibility, pressure and service. And it must be discussed honestly, not weaponised through sensational modelling and pictures of Jeremy Hunt.

“The freeze on income tax thresholds has effectively moved all doctors in the profession (aside from F1s who are also knocking on the door of the next threshold) into the higher rate of income tax. It may not look like it explicitly, but this is a tax rise on ‘working people’.

“When you fail ARCP because you only got 9 responses on your TAB”

“The ONS says health service productivity is falling. If only they could sit and watch me undertake menial tasks and battle with the tech, they may understand why”

“Please bring back mandatory bedside consultant teaching… even one hour a week of formalised teaching… I beg.”

What’s on your mind? Email us!

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

We found this article from The BMJ to be an interesting read. It looked into locally employed doctor (LED) contracts and found examples of dodgy practices, such as some LED doctors being promised speciality doctor posts that never materialise. The Royal College of Physicians recommends that once a doctor has been employed in the same speciality, by the same trust for more than two years, they should be moved to a negotiated contract appropriate to their training, like a SAS or associate specialist contract. Is this why trust grades rarely last over 2 years in a speciality?

The prostate cancer screening debate continues with David Cameron coming forward as the latest sufferer of prostate cancer. A major prostate cancer screening trial has been launched in the UK and will look at whether a combination of MRI + PSA blood tests will lead to improved mortality and morbidity endpoints.

Weekly Poll

Last week’s poll:

Overall, do you think that private healthcare benefits or detracts from the NHS?

…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!

Does Intelligence Protect You From Ideological Bias?

People generally assume doctors sit comfortably above average on the intelligence scale. They are university-educated and, for the most part, had to endure repeated application processes that were competitive in nature and self-selected individuals with the best scores and grades. But does education protect one from bad ideology?

Multiple large experimental surveys, like this one in Nature, find that analytical thinking (measured through cognitive reflection and problem-solving ability) predicts lower belief in false and dodgy headlines. Despite its unpopularity for being a devilish exam, the UCAT, the medicine entrance exam, is explicitly designed to measure innate cognitive abilities, including analytical thinking.

But conversely, we know there is plenty of evidence that shows that highly educated people can be more biased when beliefs touch on more emotionally charged topics such as politics or religion. In fact, highly educated people are effective at convincing themselves of propositions through sophisticated arguments that reinforce those beliefs. Education gives you better tools to defend the conclusions you want to keep.

Psychology tells us how easy it is for an individual to be analytically competent, but in a way that motivates them to interpret evidence in a way that preserves a valued belief. We may think reasoning exists for accuracy, but it’s also a tool for protecting who we think we are… and no one is immune from it.