Lord Lansley
Main Page: Lord Lansley (Conservative - Life peer)Specialty Medical Training
Lord Lansley Excerpts
Lord Lansley
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.
Lord Lansley (Con)
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.
Baroness in Waiting/Government Whip (Baroness Blake of Leeds) (Lab)
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—
Lord Lansley (Con)
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.
Baroness Blake of Leeds (Lab)
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.