What is the BMA Trying to Prepare Us for In the UKGP Bill?

Is the BMA’s initial 2-year grandfathering policy about to be changed?

Resident doctors received an eye-opening update from the BMA last week that has re-ignited the debate regarding the nature of the UK-graduate prioritisation bill. 

The email began with a preface in the interest of transparency. The BMA professed their desire for openness and transparency to their members. The On-call team then scrolled down to see several graphs that use NHSE 2025 data to model future competition ratios.  

What’s the Limit?

For months, the BMA has spoken about their ‘grandfathering policy’ of two years of NHS experience, preparing IMGs for the likely scenario. But in our email from the BMA, we are presented with a graph that demonstrates what competition ratios would look like if we were to use two years of NHS experience as the prioritisation group requirement, and it tells us that whilst competition ratios would be 1.93:1 in 2026/27, they would soon rise to 4.79:1 in 2034/5. 

If we define NHS experience as five years, then with no further expansion of posts, competition ratios would be at a more manageable 2.94:1 by 2034/35. With an additional expansion of training posts, competition ratios could be as low as 1.49:1 by 2034/35. The BMA do note that these numbers include assumptions such as the total number of applicants, the number of F2 doctors leaving the foundation programme and the number of new IMGs starting in the NHS. 

A Shift In Plan…

So what is the BMA doing? It would seem they are warming resident doctors up to the idea that two years of experience is simply not going to cut it if the aim is to get competition ratios down, whilst prioritising their own graduates and taxpayer investment. There is something to be said about the sloppiness of not having numbers at hand before campaigning for a two-year grandfathering policy for months on end, however.

The preparation continued with the BMA stating that, upon analysis of their member data, around 90% of their resident doctor members would fall into the prioritised applicant category, as the majority of IMG resident doctors (who are BMA members) are already in a training programme (such as IMT). 

So, BMA, we need you to define what significant NHS experience means: 2 years? 5 Years? Or more? And how will you arrive at the conclusion? A referendum within the UKRC committee or a vote amongst members?

Edit… We were right: The BMA’s resident doctor committee announced that it will be supporting five years of NHS experience as the requirement for significant experience. Would it have made a difference what the BMA concluded, or would the government have pushed it through five years anyway? That is open to the imagination.

Is Bariatric Surgery Next on the Endangered List?

For decades, bariatric surgery was the only reliable long-term solution for severe obesity. When lifestyle interventions fell short, surgery delivered results that nothing else could match. Evidence showed it led to a 49% reduction in death rate and six extra years of life.

Then came the GLP-1 agonists, which demonstrated a remarkable ability to achieve weight loss, all without the risks of the operating theatre. Naturally, it has left everyone wondering whether Bariatric surgery is the next speciality to be placed on the endangered list.

We know that for the moment, surgery still outperforms medication in terms of weight loss, particularly in the most severe cases, and most significantly, leads to a big reduction in all-cause mortality. Because these new drugs have not been around as long, the all-cause mortality data will have to wait for the GLP-1s.

Surgery may become a salvage therapy for those who plateau on GLP-1s or fail to keep the weight off upon their cessation. But we are still in the early stages. If science continues to do its thing and newer medications are created with an ability to rival the weight loss numbers of surgery, with a reduction in all-cause mortality to match, then talks of ‘extinction’ can return to the table, but for now, it seems that we may see less procedures being performed,

Have We Been Wrong to Treat Busyness As The Enemy?

Should doctors fear unpredictability more than busyness?

We’ve all experienced these two halves of our careers. Some days bring a relentless pace that will have you questioning your life choices, whilst others will have you staring at the clock, questioning why the day is never-ending.

For some, switching between the two modes of boredom and busyness happens frequently on the same rotation, but the On-Call team have been thinking: have we got it all wrong by blaming busyness for our woes, is there something else lurking quietly in the background, explaining our struggles perfectly?

The Glorification of Busyness

There is a certain sense of nobility that accompanies the ‘busy clinician’. We hear the echo of their bleeps before we see them storming through the hospital corridors, and can’t help but feel a sense of reverence towards the work they are doing. We equate being busy with being valuable. Is it any surprise, therefore, that we become imbued with this feeling of wrongness the moment we get a couple of quiet hours to ourselves in the day?

But if we dial up the busyness of their bleep, the difficulty of their cases and the logistical nightmares of the NHS, what do we arrive at?

Well, the busier the working day, the more head-clearing we need, which usually eats into our valuable evenings where we should be, well, relaxing. This head-clearing can look like the post-shift decompression period or sitting in the car for 10 minutes before going inside.

The Unknown Ceiling

But there’s an argument that doctors tolerate heavy workloads surprisingly well when they're predictable. What drains people is volatility, the uncertainty of what may present itself on the other side of the bleep. Perhaps we are wrong to focus on busyness. There is evidence to suggest that it is work unpredictability and volatility of schedules that are the predictors of stress and fatigue.

It may be tempting to jump on online forums and proclaim that we need calmer, more predictable work environments, but we know that demands which are perceived as challenges are associated with engagement in work. Medics tend to enjoy problem-solving; we have had good practice from all those years of differentiating and 25-mark questions, and many argue that the unpredictability isn’t a design flaw, it’s what draws people to medicine.

So we don’t want to eliminate unpredictability, we want to give doctors enough structure, autonomy and resources so that they can meet the challenge that unpredictability brings.

“Medics love acronyms. An ‘SHO’ hasn’t existed since 2005, yet despite being a term that covers doctors with a wide range of experience, it lives on. It is a beautiful term to describe a doctor who isn’t an F1 but isn’t quite ready to be a reg yet.”

“For those ranking jobs and considering home ownership at some point in your careers, it may be worth knowing the areas where property prices outpace salaries. Here are the least affordable four counties with the ratio of average house price to salary next to them. Surrey (14), Hertfordshire (12.8), Buckinghamshire (12.8) and West Sussex (12).”

“First Geri’s referral of the day: Patient is 96, Pls r/v, thanks.”

“Just opened my F2 psych rotation timetable. Can someone please tell me what ‘the Night Shelter’ is that I have to cover and who made it sound so ominous?”

What’s on your mind? Email us!

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

An investigation by the BBC found that hundreds of GPs said that they had never refused a fit note for mental health conditions. Of the 752 GPs who responded, 540 said they had never refused such a request.

Those on the other side of their ST1 rad interview will be no strangers to the workforce crisis facing the profession. What solutions do we have when potential demand for imaging is almost limitless, unlike, say, a surgical procedure where a painful hip can be replaced maybe once or twice, but imaged as many times as you can persuade a patient to turn up to the hospital? Here’s a brilliant piece by radiologist Dr Giles Maskell in the BMJ on how solutions can’t be solved by the radiology department alone.

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Are We Doctors Really Doing The Heavy Lifting?

Have you ever wondered how many of the patients you actively treat on the ward would have improved spontaneously? We have several quotes throughout history that touch on this phenomenon. You have surely heard this one, commonly attributed to Voltaire: 'The art of medicine consists in amusing the patient while nature cures the disease'.

This is clearly touching on the many self-limiting conditions that we see in medicine, such as viral illnesses or musculoskeletal injuries. And yes, to be clear, it would not work well in your stage 3 AKI secondary to a renal stone.

But this is exactly why 'watchful waiting' has been incorporated into many of our guidelines, particularly in primary care. What we're really asking about is how much of the improvement we see day to day is due to treatment, and how much is due to the body's natural recovery mechanisms.

This problem was highlighted by Archie Cochrane (the fella that the Cochrane Collaboration is named after), whose work heavily informed the advent of Evidence-Based Medicine. This is captured nicely in a key insight about the natural course of disease: doctors tend to intervene at the worst point of the curve. We see symptoms when they are at or near their worst, which creates a powerful illusion that our treatment caused the following improvement.

So that is why, without a solid evidence base, medicine risks repeatedly taking credit for what is simply the body's own healing trajectory. Anticipating the response from our ICU colleagues, sometimes our job is to simply provide some help with the breathing or the ‘renal-ing’, whilst we wait for the body to take over.