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Exclusive: Regions most in need of doctors still missing out under NHS workforce plan

Published on: 12 Apr 2024

The regions with the greatest need for more medical trainees are benefiting the least from the early years of the NHS workforce plan, HSJ  analysis shows.

Despite their hospitals being most in need of more trainee doctors, the South East, South West and East of England regions have not been allocated any of the 205 additional places being created in 2024-25.

London, which has long been the dominant region for medical training, received 50 of the additional places.

Universities in the three most underserved regions have also indicated they may struggle to increase their capacity for training places in 2025-26, relative to other parts of the country.

The largest expansions of training places are due to come in the later years of the workforce plan, which aims to double the number of places in England to 15,000 by 2031.

As part of their degrees, young medics undertake work placements in local hospitals, and the evidence shows a high proportion opt to continue their career in the same area. This means hospitals with relatively few training places in their region tend to have greater staffing problems.

There have long been major disparities in the provision of training places across England, which largely is a legacy of how hospital services were provided before the NHS was founded. Southern parts of the country outside London, along with East Anglia and the North West, have long been significantly under-served.

The impact of this disparity was highlighted in a report by chief medical officer Chris Whitty in 2021, which suggested the shortage of training places was exacerbating health inequalities in coastal communities.

Statistics published by the Office for Students in January suggest some of the disparities in the distribution of training places widened this year. London (Imperial) and the Midlands (Worcester) got 50 additional places each, despite already having more than their target share. The other 105 have been created in the North West, which has been underserved on training places, but has a relatively large medical workforce (see table and charts below).

In allocating these places, the OfS was following government instructions to fund capacity at new or small-sized medical schools. This significantly benefitted the North West, where Chester and Edge Hill universities have launched medical schools in recent years.

The shortfall of places in the North West was not as severe as that in the South East and East of England regions. 

The Department of Health and Social Care stressed places are being increased incrementally in the initial years of the plan, but did not respond to the specific point about the southern and East of England regions.

The OfS has been told to take account of the regional disparities when allocating a further 350 places in 2025-26. A letter to university chiefs from the OfS in January said there was a “direct correlation” between health outcomes and the number of training posts in an area. It referenced data compiled by the General Medical Council, which suggested around half of doctors completing their undergraduate study go on to practise within 50 miles of their university.

However, it suggested there had been relatively little interest or scope from universities in the South and East Anglia to create new places, compared to the North.

For example, universities in the North of England indicated a desire to expand places by an average of between 20 and 30 per cent, compared to around 10 per cent in the South and East of the country.

The letter noted: “Providers told us that there may be restrictions on their ability to grow. Reasons were varied but most mentioned either capital, placement capacity or clinical educator numbers.”

The OfS said it has earmarked a higher proportion of new places for underserved regions as part of its 2025-26 process, although final allocations will depend on universities’ ability to create the capacity in time.

Even if the earmarked allocations were achieved, it would only move the dial marginally in 2025-26. For example, training places in the South West region would increase from around 8.3 per cent of the total to 8.4 per cent, when its need is estimated at around 10 per cent. The South East would rise from 9.8 to 10.3 per cent, against a target of around 15 per cent, with the East going from 8 to 8.3 per cent, against a target of 11 per cent.

‘Vested interests’

Sheena Asthana, from Plymouth University, said the distribution of medical schools is largely a legacy of the historic locations of voluntary hospitals, which provided the first teaching hospitals.

Because these relied largely on philanthropy they were strongly concentrated in the largest cities, particularly London, and she said the distinction between specialised regional and district general hospitals in the 1960s reinforced the divide.

Professor Asthana said the case for reform has been made since the 1990s, but any radical redistribution of resources has always been opposed, which she said may reflect the “vested interests of members of the royal colleges”.

She added: “Because the distribution of medical schools is based on historical factors rather than healthcare need, it is hardly surprising that peripheral coastal and rural areas are underserved. This inequality is exacerbated by the fact that such areas have significantly older populations than their metropolitan counterparts.”

Billy Palmer, senior fellow at the Nuffield Trust think tank, said: “There have been some positive moves over the last few years with national efforts to ensure that the previous expansion of medical school places, including through new medical schools, were allocated to areas based on need and local examples such as Portsmouth who have developed their own initiatives to deliver more medical education within the city, in response to addressing the local shortage of GPs.

“However, as is often the case with healthcare in this country, issues around short-term planning, uncertainties on funding and lack of capital investment are trumping the otherwise welcome ambition to improve the distribution of medical training and, as a result, areas such as the South East, East and South West will likely lose out.”