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Peter Prinsley (Bury St Edmunds and Stowmarket) (Lab) [R]
I beg to move,
That this House has considered the Foundation Programme and its role in supporting and retaining resident doctors.
Thank you, Mrs Barker, for chairing today’s debate. First, I must thank everyone for coming and say something about my interests. As many know, I am an ear, nose and throat surgeon and I have a son who is a registrar in accident and emergency medicine. I am a fellow of the Royal College of Surgeons, I have an MD from the University of East Anglia, and my medical school was at Sheffield.
This debate is to consider the foundation programme and its role in retaining resident doctors. It is a privilege to introduce the debate, and I am grateful to all the colleagues who have come along this morning. As we all know, our resident doctors just spent six days on the picket lines; the wards were covered by others, operations were postponed and patients’ appointments were rescheduled. When the strikes ended, as they did just over a week ago, the problems did not go away. That is why I asked for the debate. If we are serious about resetting the relationship between this Government and the medical profession, as I believe we all are, we must begin somewhere, and in my view we should begin where every doctor begins: at the foundations.
Jim Shannon (Strangford) (DUP)
From this morning’s papers—perhaps the hon. Member will wish to refer to this—it seems that the Health Secretary had engaged with the British Medical Association and had an agreement with its leader. Does the hon. Member share my disappointment that even with that agreement, it went ahead with the strikes? When it had agreed a wage packet for doctors that could be anything from £50,000 as a starting wage to £100,000, it seemed that we had the recipe for an agreement, yet it was all thrown away by, it seems, the BMA.
Peter Prinsley
I heard the same thing; indeed, I met Dr Fletcher from the BMA yesterday myself and heard exactly this story, so the situation is intensely frustrating, but I believe that we can get ourselves back to a position in which an agreement can be reached.
My argument this morning is simple. The foundation programme, the first two years of a doctor’s working life, is, in its present form, not supporting and retaining doctors as it should. The problem is that the doctors are treated like numbers on a spreadsheet rather than the people they are, and some of our brightest young doctors, at precisely the moment when they need the most support, are considering leaving the NHS altogether.
Let me set out what the system does, why it is failing, what we have learned from recent attempts to reform it and what I believe we ought to do instead; but let me first refer to a Royal College of Physicians survey of resident doctors that was done in 2025, which has some interesting findings. Only 44% of the resident doctors stated that they were satisfied with their clinical training. Just 26% of the respondents felt ready to move on to the next step. About 20% of the doctors thought that the recruitment process was fair, which meant that 80% of them thought that it was unfair. About half of them want to work less than full time and, most alarmingly, only 65% of them said that they thought they would be working in the NHS in five years’ time.
Alex Easton (North Down) (Ind)
I thank the hon. Member for securing this debate. Given that the foundation programme is typically the first full-time frontline post for doctors and often coincides with the period when they are most vulnerable to stress and burnout, does he agree that the Government should be doing more to address their workload?
Peter Prinsley
Certainly we must address the workload but, as I will reveal later in my speech, there are many things that we can do to help the situation.
Let me say a bit about my own experience, which admittedly was a long time ago—
Peter Prinsley
I know—it is hard to believe. I was a medical student in Sheffield, and my first jobs were at the Royal Hallamshire hospital and the Northern General hospital. I have fond memories of the time that we started there. There was, for instance, a doctors’ mess with hot food. There was somewhere for us to live; we had residences. It is ironic that the name “junior doctors” was changed—just last year, I think—to “resident doctors”, because that is the very last thing they are. The residences have all disappeared—they have been sold off—and the doctors work shift systems, sometimes with absolutely nowhere to rest.
We had six-month rather than four-month rotations, which meant that we got to know the teams we worked with. We worked with named consultants. We had a distinct pyramidal team, with senior registrars, registrars and senior house officers, and we knew the people we were working with. They were people we had known as medical students; they were often the people who had taught us. That meant that there was a sort of support network for young doctors as they started in their careers. On the whole, the newly qualified doctors of today do not experience anything quite like that.
Jamie Stone
It is great to hear a qualified doctor talking about this matter. Health is devolved in Scotland—I must put that on the record—but in my constituency one finds that an awful lot of social care workers are calling it a day and walking away, with all sorts of unfortunate ramifications such as delayed discharge. Crucially, the support for doctors that the hon. Gentleman is talking about is not there or has been reduced. Does he agree that, if we boosted social care workers’ pay and conditions and retained them, that would help doctors?
Peter Prinsley
I absolutely agree that doctors are only part of a much bigger healthcare system. We certainly need to look after all the people involved in health and social care. Of course, that is more of a problem in geographically remote districts such as the hon. Gentleman’s constituency, where I believe it is difficult to recruit professions of all sorts.
I do not want only to sound nostalgic this morning, although of course I am. I am not arguing that absolutely everything was better in my time, because it certainly was not, but in one important respect it was better: it was designed around human beings. It understood that newly qualified doctors are individuals, not one of a herd to be simply moved across a map by a computer. It also recognised that pastoral support and clinical teams matter, and that the transition from medical student to doctor is a particularly vulnerable moment in a medical career. Let us come back to that point soon.
Today, we have a thing called the foundation programme. In 2024, the foundation programme office replaced the application process with something called preference informed allocation. What happens is that medical students list the foundation schools in order of preference, and are each assigned a computer-generated rank. The rank is not informed by academic achievement, personal circumstance, where the student trained or what they did; it simply works through the ranks and places the student accordingly.
The UK foundation programme’s 2026 figures show that of the 10,810 graduates allocated this year, 82% received their first preference. Superficially, that sounds quite reassuring, but I do not really think it is. Every year, a minority of graduates—this year it is roughly 1,900 young doctors—end up somewhere other than their first choice. The minority who do not get their first preference find themselves, aged 22 or 23, packing up their lives for a city where they know nobody. As I put it in the Chamber last month, it is a
“crazy foundation lottery that sends a doctor from Norwich to Belfast and a doctor from Belfast to Norwich.”—[Official Report, 26 March 2026; Vol. 783, c. 452.]
That is what we mean when we talk about a lottery. It is not a figure of speech, but a literal description of how the system works.
There is another reason why this headline figure flatters to deceive: the system incentivises what we call strategic preferencing. The students know the ranking system is random and that a high rank does not protect them tomorrow, so they game it. They preference the foundation schools they think they can realistically get, rather than the ones they actually want. A high first preference rate is, in part, a measure of the student lowering their ambition to protect themselves against a coin toss. That is not a system working; that is a system being worked around.
Let me say a bit about couples. Medical students often form a couple with other medical students or other people who work in hospitals, because that is the nature of a hospital. The foundation programme offers something called linked applications, but the unfairness is particularly acute. Two medical students in a relationship can choose to link their applications so that they are allocated together, but the pair is placed using the lower of the two ranks, so that if one of them is lucky in the ballot and the other is not, both are placed in the worst ranked situation. Should the algorithm be unable to accommodate both in a single school, the link is broken. A student cannot unlink once they have applied, and there is no appeal. The system quite simply cannot see that these are two people trying to begin their careers side by side. It just sees two records on a database.
That has knock-on consequences throughout the rest of the service. When foundation doctors are disorientated, unsupported and demoralised, their work does not disappear; it flows upwards to the more senior doctors, who take more and more of it on themselves. Young doctors should not be deployed by ballot into strange cities, with only limited account taken of their circumstances—their partners, their dependants, their health or their need to be near home. The claim that the current system is somehow fairer than the one it replaced is, I am afraid, one we cannot accept.
Let me talk about how we got here and the recent reform. The old system was not perfect. For many years, medical students competed on a combination of academic decile and a national examination known as the situation judgment test. The SJT was quite unpopular: it was stressful, it had unpredictable validity and there was a documented score gap that consistently disadvantaged candidates from ethnic minority backgrounds. That was a real and serious unfairness, and those who reformed the system were right to try to address it. When the students lobbied against the SJT, they had a good reason to do so, but they did not ask for a random number generator—yet that is essentially what they got.
In 2024 the SJT was abolished and academic achievement stripped out. In their place came PIA, underpinned by a computer ranking. It is hard to think of a clearer case of throwing the baby out with the bathwater. Students asked for fairness, and they were given randomness. Those are not the same thing. Fairness takes account of circumstance; randomness ignores it. Fairness rewards merit and responds to need; randomness does neither. What we have is not a reformed system, but an experiment that has gone wrong.
That is not just my view. The medical training review led by Professor Stephen Powis and Professor Chris Whitty, published last October, drew on more than 8,000 responses, 6,000 of them from resident doctors. Its very first recommendation was that
“a reform of postgraduate medical education and training is undertaken as a matter of urgency.”
It also recommended that recruitment to medical training be reviewed so that it is
“fair and equitable to all candidates”.
It is not sufficient, on any reading of the report, for allocation merely to be random. Random is not fair.
The BMA has taken a big interest in this question, which is not surprising, and I will read out some of its recommendations:
“The BMA is calling for: meaningful improvements to working lives with greater access to support services, supervision, rest and mess facilities; increased flexibility in rotations, including the option to swap placements; a guarantee that all UK graduates will be offered a foundation post, with full details provided at least 12 weeks before the start date; and any review of the allocation system to include proposals for a new recruitment process developed with meaningful consultation with students.”
There is another group of doctors that we should consider: those who will progress to become academic doctors. There is a crisis in this country of clinical academics, the doctors who teach the next generation of doctors. It has become very difficult to recruit into clinical academia. The career pathway for clinical academics has become very uncertain, and we have an emerging crisis—a real and present crisis—that must be addressed. One way to do that is to think about how we recruit foundation doctors into academic programmes.
Here is a straightforward proposal, which I hope colleagues will improve rather than simply accept. Let us return to a firm-based model for the first year of training. The F1 placement should be arranged by the medical schools, not by a centralised national algorithm, with each new doctor placed alongside peers they already know with consultants who have taught them. That is the system we had so many years ago. Medical schools know their students; they know who has the caring responsibilities, who has a linked partner, who has health needs, who has a strong reason to stay close to home. They are in the best possible position to start designing a year that makes sense for each individual.
That does not preclude movement later. F2 can broaden horizons, and specialty training will often mean relocation, but in the critical first year, when doctors are doing their first on-calls up at night by themselves, writing their first prescriptions and being present at their first deaths, they should not be alone in a city where they do not know anybody. They should be doing that with the support of their friends, teachers and colleagues they already trust. I do not think that would be particularly expensive; it might even cost less than the centralised allocation machinery we run today. Whatever we do, I offer one principle: medicine is the most distinctly human of professions and it is futile, and somewhat ironic, to try to reform it with an algorithm. The reform must be human.
Let me close where I began. Resident doctors have just come off picket lines. I do not think that in this debate we can rehearse the pay dispute, which is a matter for another day, but the strikes are not just about pay. At root, they are about a sense that the profession has been treated as though it does not matter. The individual doctor has become invisible behind the workforce spreadsheet. The Government have taken one very important step, with the Medical Training (Prioritisation) Act 2026 giving UK graduates the rightful priority for specialist training places—and that matters. Today’s debate is an opportunity to take the next step to fix the starting point itself.
We have in medicine one of the most extraordinary workforces in the world. Young doctors are among the best trained, most dedicated and most compassionate professionals. We owe them and, more importantly, the patients who depend on them, better than a lottery. We owe them the fair, well-supported, human start they deserve. I believe that would go a long way to resetting the Government’s relationship with the profession, and towards ending these damaging rolling strikes.
Jim Shannon (Strangford) (DUP)
As always, it is a pleasure to serve under your chairship, Mrs Barker. I thank the hon. Member for Bury St Edmunds and Stowmarket (Peter Prinsley) for setting the scene incredibly well. We all appreciate his in-depth portrayal of the issues. I thank him for his 40 years, as I understand, of service to the NHS. It probably does not seem that long but, on paper and statistically, it clearly is.
The hon. Member has forgotten more than I will ever know about the procedures, as I speak from a layman’s point of view. I can, however, outline what young doctors have told me, which certainly bears repeating. They work through their F1 and F2 years in fight-or-flight response. They work unsociable hours without a support network. They make life and death decisions, then return home from that night or day on duty and wonder whether they made the right decision. They wonder whether they missed something and they worry about their patients.
Doctors are empathic with their patients, they are compassionate and they understand the issues incredibly well. They follow shift patterns that on paper look like a different week but, in reality, they are working 80 hours over seven days. Off days on call keep them on tenterhooks waiting to know if they will be called in to do more work, which they will respond to out of duty and compassion. They are scheduled to finish work at 8 o’clock and on a regular basis they only leave at 9.30 pm. They start work before 8 am and take their first break at 2.45 pm, and that is not a one-off on a busy day—every day is a busy day. It is almost like “Groundhog Day”—that film where the alarm goes off at 6 am, he gets up, he does all the things, he goes back to bed and the next day starts the same—but for doctors, it is life and death.
When I asked how they function on that lack of sleep and sustenance, one 23-year-old doctor told me:
“I keep sweets in my pocket and pray for guidance.”
It needs to be more than that. I carry sweets in my pocket because, as a diabetic, if I feel myself going down, I have a chew on one and it brings me back up again, but for them, it is to ensure their concentration. Christians always pray for guidance in everything they do. They need wisdom in all the work that they do.
When I asked that 23-year-old doctor what was next for her in life, what she wanted to specialise in and what her hopes were for the future, she said:
“I am so exhausted that I don’t think anything is next.”
The exhaustion takes over. The workload is overwhelming. Put simply, she is burnt out and feels unsupported and uncertain—not because she is not a confident person, but because the workload and all that she has done have overtaken her. That is replicated numerous times, in too many doctors for us to attribute it to personality. It is not her personality, because she is a lovely young lady; it is the current procedure.
I am very pleased to see the Minister in his place. He has empathy and understanding of what we need for our doctors. I am confident that his reply will encourage and hearten us. Hopefully, it will also help with the expectations on young doctors from families and with the paperwork—that has never been more onerous, yet there is no time for them to set aside to do it because they are overwhelmed by the workload in wards and A&E and surgical work supporting doctors. If their placement is in a smaller hospital, they do not have the support of house doctors or consultants during evening shifts, and the pressure is immense. I said earlier that it is overwhelming, and it is, to the extent that they sometimes just say to themselves, “My goodness me, how am I going to keep going?”
We all understand that medicine, by its very nature, is highly pressured and that skills are learned not only in books, but in practice. For the junior doctors I met back home, it is a physical practice—they learn by what happens in the ward. Home-grown students are not being retained, however, so changes to the system must take place, and take place soon. In his introduction, the hon. Member for Bury St Edmunds and Stowmarket referred to one doctor who went from Norwich to Belfast and another who went from Belfast to Norwich. It is unreal, and it seems idiotic—I use that word in a very gentle way—that that should take place.
Training a doctor in the UK costs the taxpayer roughly £230,000 to £327,000 per student from medical school through foundation training. That is a big sum of money, but we are training someone on whom we depend to be the best in a critical situation in hospital. Who of us, when we have a chat with our doctor and ask for their opinion, will not accept what the doctor tells us as gospel? We trust that we can depend on that doctor’s diagnosis of the disease, so that money must result in qualified, capable doctors and not just young people who could have made a difference if they had been given the support and reasonable working hours with reasonable pay to make all the on-calls and missed sleeping patterns worth it.
Alex Easton
Another problem we have in Northern Ireland is that many doctors are moving over to private care, which is leading to shortfalls of NHS doctors. Is that something we need to tackle to retain doctors in the NHS?
Jim Shannon
It certainly is. To be fair, I do not know of any doctors who have made the journey, but I know that they are certainly aware of the bigger wage packets available in, for instance, Australia, Canada and New Zealand, where they can go for two or three years. The problem is that if they go away for two or three years, they may never come back. It is not just a matter of going to earn big money to pay off student fees and move forward—it is more than that. It is a critical issue, so the hon. Member is right to mention it.
I wonder whether the Minister would consider in his response the option of having student doctors sign a retainer that would keep them in the NHS, and consider providing a bursary for their fees. I understand that Wales does that; I know it is a regional matter for us in Northern Ireland, but if Wales can do it, there are certainly points for us to consider.
I have constituents who have gone to Wales from Northern Ireland for the purpose of going away for two or three years—I think of one young lady in particular whose family I know well. She went to Wales and completed her full studies there at university and in the hospitals. Then, of course, what happens? She meets a young Welsh guy and he sweeps her off her feet and the next thing we know, she is engaged, she is married—she is never coming home.
We will not have the advantage of that young lady’s expertise, but Wales will. I am very pleased that Wales will have that expertise, because she is an excellent student and person. I am sure there are many other people for whom the same thing has happened, because love is a funny thing, is it not? When it gets you, you cannot get off it. You are caught forever. From my point of view, my wife has stuck with me for 39 years—my goodness, she needs a medal.
I have spoken at length about intelligent, capable young people who feel overworked and underappreciated but who, most importantly, feel overwhelmed. That can change with support—support that must echo from here not with words, but with appropriate pay and staffing. If we do that, we will retain the best of the best within the NHS. I do not doubt that that is the desire of the Minister and this Government, and of every hon. Member here.
Ayoub Khan (Birmingham Perry Barr) (Ind)
It is a pleasure to serve under your chairship, Mrs Barker. I thank the hon. Member for Bury St Edmunds and Stowmarket (Peter Prinsley) not just for securing this important debate, but for his service in this sector.
I am shocked by what the hon. Member set out about the algorithm and how students or resident doctors are placed in the embryonic stages of their profession. In fact, I am astounded—I suspect many parliamentarians will not know this, and certainly the public will not be familiar with the process—that there is no appeals process. I suspect that something could quite easily be incorporated, within certain parameters, so that not everybody gets to appeal, but it is possible in exceptional circumstances. That must be right.
When we talk about the future of healthcare in the United Kingdom, we are really talking about the people who hold it together every single day, and resident doctors are at the core of that. These individuals have committed years of their life to rigorous study, they have worked long hours and they have an unwavering dedication to patient care, yet at one of the most critical stages of their career, many feel unsupported, overstretched and uncertain about their future within the NHS.
This is where and how the foundation programme plays a vital role. It is not just about a training pathway; it is the bridge between medical school and a lifelong career in medicine. At its best, the foundation programme provides structured learning, broad clinical exposure, and the opportunity to develop confidence and competence in real-world settings. It shapes not only skills, but professional identity.
If we are serious about supporting and retaining resident doctors, however, the foundation programme must do more than simply place doctors into rotations—it must actively nurture them. That means ensuring fair workloads, access to high-quality supervision and protected time for education. It means creating environments where doctors feel valued, heard and supported not just as clinicians, but as people. Retention is not just about pay or contracts; it is about culture. When doctors, especially foundation doctors, feel respected, when their wellbeing is prioritised and when they can see a sustainable future within the system, they are far more likely to stay and build their careers in the United Kingdom. One of the biggest problems I see around Birmingham is new and young doctors talking about moving abroad.
We cannot ignore the reality that many resident doctors have felt pushed to the point of taking industrial action. Strikes are never a first choice; they are a last resort when people feel that they have no other way to be heard. Concerns about pay erosion, rising living costs and consistently long and demanding hours have created a situation where many doctors feel undervalued and exhausted.
I went to a picket line outside Queen Elizabeth hospital Birmingham. So many young doctors there talked about how they were unable to live in close proximity to the hospital; they were living many miles away, simply because of accommodation costs. That is quite surprising, because we often hear people talk about junior doctors earning so much money. But if in reality, after tax and all the other expenses, junior doctors—people who save lives—cannot afford to pay for accommodation near the hospital, that shows how our system is broken.
If we want to be honest about supporting doctors, we must acknowledge that their concerns are not unreasonable. A system that relies on goodwill alone is not sustainable. Extra investment in the NHS means very little if it does not translate into better pay, safer working conditions and genuine support for the workforce delivering care every day. The Government must do more: not just words, but meaningful action. That means engaging constructively, addressing the pay concerns fairly and ensuring working conditions that allow doctors to provide safe, high-quality care without burning out.
If we invest properly in the foundation programme and support doctors throughout their early careers, allowing them an appeals process for exceptional circumstances and giving them the basic support in addressing their current challenges, we are investing in the long-term strength of our healthcare system. Supporting resident doctors is not optional—it is essential. When we support them, we do not just retain doctors; we safeguard the future of patient care.
Dr Danny Chambers (Winchester) (LD)
It is an honour to serve under your chairship, Mrs Barker. I congratulate the hon. Member for Bury St Edmunds and Stowmarket (Peter Prinsley) for another insightful speech; this time I will avoid comparing the anatomy of human and dog ear canals—we have covered that already.
We always rightly start these speeches by paying tribute to NHS staff, doctors, nurses and everyone involved in patient care, especially given the pressures on them as a result of sheer patient numbers and working in systems that can make the job even more stressful and pressurised than it already is. They are caring for severely injured or very ill people at the toughest moments of their lives. The emotional burden of caring for people who could be dying is difficult in itself, but resident doctors work in a system that adds extra pressures and conditions that can add stress alongside that. We cannot pay enough tribute to them for even surviving in those areas.
One of the best books highlighting the plight of resident doctors that I have read is Adam Kay’s “This is Going to Hurt”. It did a lot to help the public to understand just how difficult it is for a doctor to not know where their training place is going to be. It is where they are going to be forced to live and work for several years—a place where they may not have any friends or family; they might be taken away from family and spouses. They might have dependants and children. It is really difficult to plan a career, especially such a difficult and challenging career, when working with that level of uncertainty. I lived with medical students when I was a student at Liverpool University and have followed their careers since. The challenges that the hon. Member set out have been reflected in their lives and careers.
I support the Government’s ambition to increase medical school placements. That is important. We have a recognised workforce shortage in the NHS, so that is an obvious thing to do, but we must ensure that we do not carry on falling into the same trap. The previous Government, under Boris Johnson, said that they would increase medical school placements—and they did, but without providing the infrastructure for training resident doctors who want to go on to specialised training. That obvious bottleneck was going to filter through. No mechanism was put in place to ensure that the NHS would have the capacity to train those extra medical students when they finished their F1 and F2.
In Winchester I speak to many resident doctors, and even to their parents. Those resident doctors have gone through university, sometimes getting themselves in a fair amount of student loan debt, and are working hard on their F1 and F2. The stress of not knowing whether they will get a training placement is overwhelming, frustrating and for us, as a society, ridiculous because we are short of doctors. How have we ended up in a situation where we are training students and resident doctors, but cannot give them the further training places to continue? I urge the Government to ensure that any training places will filter all the way through for the rest of that person’s career.
We know that the last Government not only thought it sounded good for winning votes to say that they would increase medical school placements, but said that they would build 40 new hospitals, though there was absolutely no funding—putting votes before a genuine long-term plan for the NHS. We then come up against a brick wall of reality. People working in the NHS end up suffering and the people who rely on the NHS—everyone—end up not getting the service that they voted for.
The Liberal Democrats welcome the Minister’s statement about increasing training numbers, especially for people from more disadvantaged backgrounds. It is important that we look at the diversity of the professions. Certainly within the veterinary profession, socioeconomic diversity is not what it should be; it does not reflect society. A profession—whether the medical profession or another—offers a better service to society if it better reflects it. I once heard someone say that talent is everywhere, but opportunity is not. It is the job of all professions to ensure that we get the people with the talent enrolled on courses so that they can have fulfilling careers and offer much back to society.
The statement is a really good first step, but it is a bit vague. The Minister writes about underserved parts of the UK seeing new medical spaces; how many will there be, and how will that be delivered? Will current medical schools increase their capacity? Will new teaching hospitals open to support it? The target is to place
“up to 25% of students at participating medical schools…to local foundation training places”.
How many medical schools have indicated that they want to participate? That will be fundamental to how this policy gets delivered.
To reiterate what the hon. Member for Bury St Edmunds and Stowmarket said, we need to treat medical students and resident doctors like people; they are not just numbers. Working conditions are as important as pay, and to improve working conditions we need to double down on improving social care to avoid delayed discharge and corridor care. The doctors delivering treatment will feel that they are doing a better job, and will not feel under pressure as a result of being unable to deliver the care that they want and that patients deserve.
We also need to ensure that we have a happy, resilient, passionate and excited workforce going forward. The Minister has been asked constructive questions. I ask him not to repeat the previous Government’s mistakes of talking about increasing hospital numbers and medical students, while creating a whole generation of doctors who cannot go on to serve their communities and have a fulfilling career.
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
It is a pleasure to serve under your chairship, Mrs Barker. I congratulate the hon. Member for Bury St Edmunds and Stowmarket (Peter Prinsley) on securing this debate and giving a great speech. I need to declare an interest as a consultant paediatrician in the national health service, a member of the Royal College of Paediatrics and Child Health, and a member of the British Medical Association.
Going back a little while to when I was young—in fact, we are going back 25 years—I graduated as a doctor in 2001. I had done a five-year degree and I had provisional registration with the General Medical Council. In order to get full registration, I had to complete a year as a pre-registration house officer, most commonly referred to as a house officer. That was six months of medicine and six months of surgery in adult care in either order. It was, to some extent, an extension of medical school. Indeed, it was supervised by the medical school in terms of placements, and almost everyone—I say “almost”; I will come back to that in a moment—stayed local.
In the process that I followed in Newcastle, where I was a student—I am recollecting this from 25 years ago—we had to apply for two medical and two surgical jobs. I applied for the Royal Victoria Infirmary and the Freeman hospital, but there were other options across the north-east where people were involved in training and medical school placements, such as Carlisle, Sunderland, North Tyneside—which was particularly popular at that time—South Cleveland and others. As with any other job, one was shortlisted, interviewed and potentially offered a job. The system worked so that, if a person was offered both jobs, they had to pick one. When the first round went out, people said which job they wanted and that was theirs. All the other jobs that were not allocated were put back into round two, people applied again, and by the time it got to round three essentially everyone had a job.
The benefit of the system was that everyone knew that they had a job in the region where they trained to complete their full registration with the GMC, and the Government knew that all the people they had invested in for that training would become fully qualified doctors, provided they put in the requisite effort and attainment.
However, changing over deaneries was extremely difficult. I applied for the RVI and the Freeman, and I got offered both. That was straightforward, but then I fell in love. I was proposed to, I accepted and I planned a wedding for no more than a week before I graduated. I did not fall in love with another member of hospital staff; I fell in love with a farmer, and farms are quite difficult to shift.
I then decided that I wanted to move to Nottingham deanery. It is fair to say that Newcastle deanery was not keen on that idea, although it was supportive, and Nottinghamshire deanery was really not keen on the idea because it had to fit an extra person into the system. It made that clear, saying, “Well, you’re not having a job in a big teaching hospital.” That was fine: I just wanted a job near to where my husband’s farm was. I was allowed to move deaneries under those special circumstances.
I first spent time at Lincoln under Dr Patterson, a wonderful consultant, as a young doctor. He was a respiratory physician, and I very much felt part of his team. I then went to Mansfield, where I worked for Mr Moulton, an orthopaedic surgeon. He was a lovely man; we used to do French verbs together during knee operations. After that, I worked for Miss Patterson, a vascular surgeon.
As the hon. Member for Bury St Edmunds and Stowmarket put it, I very much felt part of a firm or part of a team. There was continuity of care, as I was looking after my consultant’s patients. I was not part of a massive group of people performing a list of tasks for a whole range of consultants on a group of patients who I did not know, which is how it can be for many junior doctors now.
The other thing provided at that time was accommodation. Part of the system with a PRHO job was that accommodation was provided for free, on the hospital site or very close to it, for the first year. That meant that when junior doctors were doing those two six-month jobs straight out of medical school, they had accommodation.
In their wisdom, the people negotiating the pay and conditions decided to give that accommodation up for a little bit of extra money. At the time I thought that was mad, but since I had passed that stage, at the time I considered that it was really none of my business. However, I think that it caused a problem, particularly because the European working time directive has meant that instead of working really long shifts, people work much shorter shifts but have much longer travelling times. I was working long shifts but not having to do a lot of travelling. Junior doctors now have to do shorter shifts—more of them, on a much less flexible rota, to get all the required shifts in—and they are also travelling for miles at the beginning and end of each shift. I think that change has been counterproductive; I wonder whether the Minister has any thoughts about it.
The other thing is that the system was based on merit—whether or not I got the job at the RVI or the Freeman was based on merit. I had to apply. I had to say that I had done things such as presenting at an international conference as a final-year student. That sort of thing was considered important, as was getting good grades in my exams or in my project work at medical school; now it is not.
I just wanted to examine what happened between that time and now. In 2005, the then Labour Government introduced a modernising medical careers programme, which changed the one-year foundation programme to a two-year foundation programme—I am not clear why that was thought necessary—and the placements were changed from six months to three or four months in duration. I agree with the hon. Member for Bury St Edmunds and Stowmarket that that is too short for someone to really get into a job, and to understand the team they are in and what they are doing, before they have to move on again. People have virtually just arrived and then they are going.
There was then the medical training application scheme, or MTA scheme, in 2007, which was a national scheme. There were lots of errors and data breaches. The Secretary of State apologised, and we went back to the deanery approach. There was then a lot of concern that that system was not fair, and that it was stressful; it required people to perform well in exams, and people did not like that very much.
So we have gone to the Oriel system—this preference-informed allocation system that matches people with places. In the engagement process before it was brought in, there were 14,500 responses, mostly from students, and 66% of respondents said they wanted the system, while about 30% said they did not, so it was brought in. The education performance measure and the situational judgment tests, which have been referred to, were removed, and a lottery system was brought in. Essentially, it means that junior doctors are given a completely randomly allocated number, based on nothing but chance. Junior doctors are then allowed to express a preference for particular foundation programmes.
However, when I refer to foundation programmes, I mean areas of the country. As I said, in the case of Newcastle that can mean an area that goes all the way from one coast to another—for example, right down to Middlesbrough and up to Hexham and Berwick. Those are not small areas; they are quite chunky bits of the country to travel around, requiring many hours of travel, from north to south to east to west, in some of them.
Nevertheless, applicants get to express a preference. The computer system will allocate places on the basis that if someone’s first preference is available, they get it, but if it is not they effectively get put back in the box for later. The computer will go down the list until it has allocated all the first preferences and, as the hon. Member for Bury St Edmunds and Stowmarket said, quite a lot of people do get their first preference although, as he also said, whether or not it was their first preference in truth is another matter.
Then an applicant gets to look in the foundation area that they have been allocated to, and to express a preference regarding the jobs within that region. The computer, using the same number—if the student was lucky the first time, they are lucky the second time—goes down the list and allocates them. If they are not allocated, it has to go round again and allocate them a later preference. That means that people either get their first preference or go very much further down the list: a Newcastle medical student, as I was, could get sent to Penzance, which is a lovely place but a long way from Newcastle. There is nothing the student can do about that. They have no control over their life. Even if they are the best-performing medical student in every capacity in the whole country, they still get sent where they get sent—and that is tough.
Peter Prinsley
Some time ago, when I came here, I had working with me an intern, Dr Harry Dunn, who was a medical student at Cambridge University. He graduated last year. He came top, not only of the University of Cambridge medical student cohort, but of the whole of the University of Cambridge, so he was the top student of his year. He was offered a foundation post in Northern Ireland. He chose not to take it, and has now gone into consulting, having given up medicine. That is an extremely sad example of an unintended consequence of this crazy lottery.
Dr Johnson
I congratulate that person on his prowess in university. He is clearly an incredible person, and it is a shame that he has been lost to medicine. I am sure Northern Ireland is a great place to work, and it is disappointing that he did not want to go there, but he should have been able to apply for the jobs that he wanted in places where he wanted to work, and to compete fairly for them. That is a bit stressful and competitive—but getting into medical school is competitive.
You may not know this, Mrs Barker, but the hon. Member for Bury St Edmunds and Stowmarket and I grew up on the same street, in the same town, and went into similar-ish careers. We competed for medical school places and for our jobs. We are all here today having competed against others for election—that is the reality of life. To remove the competition, which is based on meritocracy, and replace it with a random allocation is more unfair and stressful than the alternative.
One of the issues raised about the old scheme was that it was difficult to recruit in some areas. The competition for the best jobs, or at least those perceived to be the best or most wanted jobs, means that some areas of the country and some specialties could find themselves with the people who did not succeed in getting the jobs they wanted. How do we manage that? It used to be managed with rotations. When people went to the interview for specialist jobs, they would be called in one at a time and told, “These are the rotations available. Which one do you want?” The best jobs—the most popular ones—would be mixed with the least popular, so that would mitigate the problem.
There is one issue that I want to raise briefly. Some medical schools in the UK, including Newcastle, have overseas campuses in Malta, Cyprus and Malaysia. Some British people have gone to those branches of UK medical schools and have found themselves completely excluded from places in the United Kingdom under the medical training changes that the Government have made in the past couple of months, which seems wrong. We talked about that when the Bill went through, and the Minister was keen to reassure us that all would be well, but we have found that British students have not been able to get jobs in the British training programme. Will the Minister look at prioritising at least those who went to medical school before the changes for British jobs?
The current system gives junior doctors—resident doctors, as they are called now—no agency, no control, no appeal and no alternative. It is clearly unfair. Could the Minister update the House on how he intends to fix the system?
The Minister for Care (Stephen Kinnock)
It is a real pleasure to serve under your chairship, Mrs Barker. I congratulate and thank my hon. Friend the Member for Bury St Edmunds and Stowmarket (Peter Prinsley) for securing this vital debate, and all the hon. Members who have contributed. I pay tribute to my hon. Friend’s significant and distinguished career and experience in our NHS. I take the opportunity to thank resident doctors up and down the country for the vital contribution they make to our NHS and to treating the patients it serves.
As my hon. Friend said in his opening speech, the UK foundation programme is a central part of the pathway to becoming a doctor, bridging the gap between medical school and specialty or general practice training in the NHS. It supports newly qualified doctors to develop the clinical and professional skills needed to deliver safe and effective care, preparing them for progression into core, specialty or general practice training. Resident doctors who currently work in the NHS have made it clear that they have concerns and frustrations with their training experience. We are committed to listening to and addressing that and to improving the training pathway for the medical workforce, for the benefit of NHS services and patients.
Through phase 1 of the medical training review we conducted extensive engagement to ensure that doctors, patients and NHS leaders had the opportunity to describe what works well in medical education and training and what needs to improve to meet the needs of both resident doctors and patients. The phase 1 diagnostic report was published last year and made 11 recommendations centred on four key priorities: more flexible training; removing the divide between service and training; ending the damaging recruitment bottlenecks and rewarding teams where doctors feel valued.
The implementation team, led by Dame Jane Dacre, who has been appointed as the independent chair for this work, will now work with doctors, the General Medical Council, the Medical Schools Council, royal colleges and other bodies to drive this much-needed change.
Dr Johnson
Could the Minister highlight the timing of that in relation to the workforce plan, and when that will be published?
Stephen Kinnock
The workforce plan will be published this spring, so there is not too long to wait. It has taken a little longer than we initially hoped, but we think it is really important to ensure that it is anchored in very solid engagement with our partners and stakeholders.
Earlier this year, the Government delivered fast-track legislation to put UK medical graduates at the front of the queue for foundation and specialty training places, reducing uncertainty and ensuring that they can progress to full registration as doctors. We have confirmed that all eligible UK medical graduates will be offered a place on the foundation programme this year. Of course, our fast-track legislation seeks to rectify the unforgivably reckless and damaging decision made by the previous Government to remove the resident labour market test after Brexit, which in many ways is the root cause of the mess created by the neglect and incompetence of the previous Government over 14 years.
I turn now to the process for allocating places to applicants for the UK foundation programme and the steps the Government are taking to improve it. We recognise that the location a foundation doctor is assigned for training has both professional and personal impacts. The four UK Health Departments determine the number of places available each year based on workforce planning across the continuum of postgraduate medical education and training. Applicants are allocated across the UK using a nationally applied preference informed allocation system, which has been extensively commented on in the debate.
The PIA system was introduced in 2024, following extensive engagement with the four UK statutory education bodies, medical students and key stakeholders. The move to the new system aimed to address concerns that the previous system was unfair and stressful for applicants and that there was a lack of standardisation within and across schools. It is worth mentioning that the consultation on the PIA system received over 14,500 responses, 66% of which favoured a move to the PIA option against the status quo. There were 106 organisations among those 14,500 responses. It was an extensive consultation with fairly conclusive feedback on the change that was required.
Ayoub Khan
In relation to the consultation on the PIA system, does the Minister agree that, if there is no appeal process in the system, it cannot be fair, because there will be extenuating circumstances that ought to be considered? That is something I suspect the Government could implement relatively easily.
Stephen Kinnock
It is worth highlighting that around 82% of applicants get their first preference. That is a significant improvement—it was 71% in 2023. We are taking steps in the right direction, but we would love to get to 100%. It is difficult to get to 100% of anything in a large and complex system, but that is our aspiration. Of course, those who do not get their first place are welcome to re-engage with the system, and efforts are made to ensure they get their preference, although we do not always succeed in that process. I will take the hon. Member’s question away and discuss it with my colleague the Minister of State for Health—she leads on this portfolio, although she was not available for this debate—and we will write to him with further clarifications on the important point he makes.
The introduction of the PIA was broadly supported by stakeholders, and I am pleased that we have seen an improvement under this system in the number of students allocated their first preference programme. As I said, 82% of applicants to this year’s foundation programme were allocated their first preference, up from 71% in 2023. However, we are committed to ensuring that the system remains fit for purpose. NHS England will conduct a review to ensure that it is still working for applicants. The timelines of that review will be confirmed in due course.
Furthermore, although some individuals may want to move away from their university area for foundation training, some need greater certainty, for a range of reasons, about their foundation placements. In the last two years, we have supported a portion of students in three UK medical schools by allocating them to foundation programmes in their local area. Last Friday we went further, announcing that we will work with medical schools and foundation schools to extend that support to trainees across the country from disadvantaged backgrounds. Providing a post close to where they live will mean more stability for trainees and will support employers in developing a local workforce.
I would like to say a final word on the PIA. I think we all accept that it is not perfect—it is very difficult to have a perfect system—but I take issue with the characterisation by some Members in the debate that it is a random system. We do not agree with that characterisation. We are clear that the system in place is enabling people to clearly articulate their first preference, and in the overwhelming majority of cases they are getting their first preference. That does not feel like a random system to us, but we absolutely accept that it is not perfect, and there is always room for improvement.
Let me turn to rotations. We recognise the importance of stability for doctors in training and the impact that frequent relocations can have on wellbeing, retention and workforce planning. Following the 2024 resident doctors agreement, the Department of Health and Social Care conducted a review of rotational training and found that rotations can provide valuable breadth of experience. However, we know that in some cases they can disrupt learning, wellbeing, team integration and patient care. To tackle that, NHS England is developing pilots under the medical education and training review to test longer placements and more flexible arrangements for less-than-full-time trainees. The evaluation of those pilots will inform future policy decisions on placement length and continuity benefits.
I turn now to the wider working conditions for resident doctors. It is essential that we create a supportive environment for doctors throughout their training that looks after their health and wellbeing. NHS England’s resident doctors’ working lives programme continues to implement several measures aimed at supporting resident doctors, encouraging them to stay in training and the NHS and reducing overall attrition. That includes measures such as the less-than-full-time training options to allow trainees to continue to work in the service and progress with their training on a reduced working pattern where that is beneficial for their personal circumstances.
We have made significant progress over the past year to improve the working lives of resident doctors, including agreeing an improved exception reporting system, which will ensure that doctors are compensated fairly for additional work, and rationalising statutory and mandatory training to reduce unnecessary burden and repetition.
Dr Johnson
The Minister talked about less-than-full-time training, which has obviously had an impact on the number of doctors we need. The Secretary of State said before the general election that if Labour was elected, it would double the number of medical school places. Is that still the Government’s intention?
Stephen Kinnock
Yes, that is the Government’s intention. Obviously, we have had some challenges in April around our hope that we could create 1,000 additional places. We have not been able to do that, unfortunately, because of the reckless decision of the BMA to go back out on strike. The absorption of huge capacity, as well as operational issues, has meant that we have not been able to do that.
Dr Johnson
I thank the Minister for that answer, but I believe that it relates to postgraduate training places. I was asking whether it is still the intention to double the number of medical school places?
Stephen Kinnock
Sorry; I misunderstood the question. Yes, it is still our intention to double the number of medical school places.
The Government remain committed to publishing a 10-year workforce plan this spring to set out how we will create a workforce ready to deliver the transformed service that we set out in the 10-year health plan. The 10-year workforce plan will ensure that the NHS has the right people, in the right places, with the right skills to care for patients when they need it.
NHS staff told us through the 10-year health plan engagement that they are crying out for change. The workforce plan will set out how we deliver that change by making sure staff are better treated and have better training, more fulfilling roles and hope for the future.
I thank all hon. Members for taking part in this important debate.
Ayoub Khan
I hesitate to interrupt the Minister’s final remarks, but will he shed some light on the strike by young junior doctors? Queen Elizabeth hospital in my constituency serves many local residents. The young doctors I have spoken to talk about the cost of living and the inability to support themselves, at the point when they are entering an exciting career. What more support will the Government provide them with?
Stephen Kinnock
That gives me an opportunity to highlight the fact that this Government have delivered a 29% pay increase for resident doctors. Although I absolutely accept that, prior to July 2024, over 14 years of dealing with an incompetent Government, they suffered from being underpaid and neglected, and we had to seek to fix that—we have done that in good faith and with good will—there have to be limits to what we can offer. The sky is not the limit; the limit is the deeply damaged and parlous state of the public finances that were left to us when we took over in July 2024, and the significant pressures across every aspect of Government.
We implore the resident doctors and the BMA to come back to the table. The Secretary of State believed that he had a deal with the officers of the BMA, and those officers then took that deal to the broader committee. There is no doubt that that committee has ideological motivations, and it refused to accept the deal. We are now in a very challenging position. The Secretary of State has asked several times for a face-to-face meeting with the entire committee, and that request has been refused. We have to make progress, but I simply remind its members that most of our constituents would see a 29% pay increase as a pretty positive deal.
Jim Shannon
I thank the Minister for that comprehensive response to the hon. Member for Birmingham Perry Barr (Ayoub Khan). So near and yet so far—that is the way I see it. I have always supported the Secretary of State in his endeavours to secure a deal, and it is incredibly frustrating to get so close to one and for it then to fall down. I am probably reiterating what the Minister said, but although the deal fell and we did not secure what we all hoped for, does the Department intend to continue engaging with the BMA and the junior doctors to secure a deal? We have got so close that we must be able to get this over the line.
Stephen Kinnock
The short answer is yes, absolutely—our door is always open. We have to find a constructive way through this. I accept that it is not always just about pay; it is also about broader terms and conditions—exactly the things we have been debating today. That is why I was so excited by the fast-track legislation we brought forward specifically to address the bottlenecks and the impact of the disgraceful decision under the previous Government to remove the resident labour market test. We are seeking to fix all those problems, and we need a constructive partner on the other side of the table to do that. We are starting to see in opinion polls that public support for the action taken by the BMA and resident doctors is eroding quite seriously, and I hope they take that into account before they make their next decisions.
Dr Caroline Johnson
As a doctor, I feel uncomfortable with the morality of going on strike and leaving patients to suffer in order to get more money for oneself. I think the morality of the strikes is outrageous. However, does the Minister regret the repealing of the minimum service levels legislation, which could have enabled the Government to put in firmer boundaries around the strikes to prevent harm to patients? Will the Government consider banning doctors from striking altogether, as a Conservative Government would, in the same way that people in the Army and the police are banned from striking?
Stephen Kinnock
The hon. Lady’s point about morality is important and interesting, but people also have to be able to put bread on the table, pay the mortgage or rent, and feed and clothe their kids. Morality is fine, but it does not put bread on the table. The two things are very important.
On the retrograde steps the Conservative party is proposing around industrial relations, that is just not what the Labour party is about. The Labour party is about constructive, positive industrial relations and respect. It is about treating the workforce and unions with the respect they deserve and finding a constructive solution. We do not want to move to some kind of police state, where we restrict the rights of trade unions. We see the right to organise and go on strike as a fundamental right of citizens in our country, and it would be a retrograde step to remove it. It is pretty extraordinary to hear that suggested by the Conservative party when we live in a liberal democracy. So the answer to the hon. Lady’s question is no. I believe we will find a way through this dispute. It will be hard going—it will be two steps forward and one step back, I am sure—but in the end I believe we will get there.
Dr Johnson
I thank the Minister for being extremely generous with his time. He says the Government will not consider removing the right of doctors to strike, but he seems to be going further and suggesting that doing so would be wrong in principle. Do the Government therefore intend to allow the right to strike for those who are currently not allowed to, such as the police and armed forces?
Stephen Kinnock
We have those restrictions on the right to strike in the police and the armed forces for obvious reasons of national security. I think that is a very different issue; our critical national infrastructure must be protected, and there cannot be any dispute about that.
We are dealing with a workforce whose pay and conditions had clearly been neglected. The previous Government used the moral argument the hon. Lady was trying to make as leverage to keep pay and conditions down, which I would say is a deeply immoral position to take. The right to be a member of a trade union and to go on strike is relevant to certain sectors of our labour market, and that right, where it exists, should be protected; where it does not exist, that is a completely different debate.
I thank all Members for taking part in this important debate. The Government are taking important steps, and we remain committed to improving the working lives and prospects of resident doctors, and to ensuring an effective foundation programme.
Peter Prinsley
I thank all hon. Members who came to speak in the debate. I particularly thank the hon. Members for Strangford (Jim Shannon) and for Birmingham Perry Barr (Ayoub Khan), who gave very interesting Back-Bench contributions. I also thank the Minister and the Opposition spokespeople—the hon. Members for Sleaford and North Hykeham (Dr Johnson) and for Winchester (Dr Chambers)—for their contributions. It is quite true that the shadow Minister and I grew up on the same street—probably about 10 houses apart, but many more than 10 years apart.
This has been an interesting debate, whose purpose was to highlight the plight of foundation doctors. As we have said, if we can fix the foundations, we will be able to fix the problems we have with our young doctors. I definitely think that this industrial dispute, which has been rolling and rumbling on for several years, is solvable. It sounds as though we were close to solving it and particularly to attending to the conditions of young doctors.
Paula Barker (in the Chair)
Order. I remind the hon. Member that this is not a chance for a second speech; it is just a winding-up speech.
Peter Prinsley
I will wind up, then. I thank everyone very much, and I look forward to seeing success in the future.
Question put and agreed to.
Resolved,
That this House has considered the Foundation Programme and its role in supporting and retaining resident doctors.