If you are anywhere near the NHS, you cannot miss the growing anger. Doctors graduating from UK medical schools, exiting foundation years, competing for specialty training posts, and finding the road bumpier than anyone promised. Some eventually get through. Many do not.
The 2025 competition ratios published by NHS England triggered a cacophony. 91,999 applications for 12,833 posts across all specialties. Core surgical training ratios climbing steeply. Instagram reels describing it as "soul destroying." The BMA calling it a bottleneck, a scandal, musical chairs.
The proposed solutions are predictable: increase training posts to match graduates, prioritise UK graduates over international medical graduates, do system planning. All of which means: spend more billions within the same model.
Three out of four applicants to medical schools do not get a place. The idea of entering a competitive profession comes early. Medicine has always been competitive. The question worth asking: who decides what the population needs, and how should workforce investment follow?
The loudest voice problem
Currently, consultant recruitment is driven by professional bodies, specialty associations, and clinical directors walking the executive corridors. The loudest voice gets the next appointment.
The British Association for Paediatric Nephrology recommends one consultant per 0.5 million population. The GMC recognises 65 specialties and 31 subspecialties. Multiply the logic of every specialty body arguing for growth across all of them, and the NHS would consume the entire treasury several times over.
How should a healthcare system decide what specialty to invest in, where, ensuring value for the population and the taxpayer? The answer is strategic commissioning. But strategic commissioning needs analytical capability that most ICBs do not currently possess.
Population need, not professional demand
At STRASYS, the Decision Intelligence engine for healthcare, we have built this capability. Population Need Segmentation maps what the population actually needs, set against what is currently offered. The Consultant Workforce Optimisation System triangulates clinical activity, job plan data, and financial performance to reveal where consultant capacity is trapped or misallocated.
Together, they answer the question the system refuses to ask: does this region need more cardiothoracic surgeons, more geriatricians, or fewer paediatric nephrologists?
I can attest to this personally. I wrote to my Medical Director in Newcastle saying the trust had no reason to replace my post because there was not enough work to justify the cost. The burnt bridge embers are still smouldering. But the question stands: who should decide, and on what basis?
Naeem Younis, STRASYS CEO, argues that the reshaped ICBs should publish strategic recruitment blueprints informed by population need analysis. Stop advertising substantively for backlog-driven roles. Use locums and waiting list initiatives for temporary demand. Do not replace retirements automatically. Appoint on population need. Be transparent about the logic, backed by data.
Being transparent about the money enables constructive professional engagement. It shifts the conversation from positional bargaining to a shared understanding of where investment creates the most value.
Retention before expansion
Workforce planning without good retention strategies is trying to fill a tank with a hole. The competition ratio data reveals vacancies appearing mid-programme. Poor specialty choice. Poor training experience. Poor working conditions. Doctors leaving for Australia, Canada, New Zealand. Better money, better conditions, different weather.
Reducing competition ratios to close to 1:1 would add several recurrent billions to the annual resident doctor salary bill and training budgets. Once those trainees finish, the pressure compounds: more consultant and GP posts needed, each carrying the £5.5 million career cost we have documented.
Strategic recruitment and meaningful retention for those who would rather stay and compete for the final posting will improve the quality of learning, quality of care, and reduce the costs of churn. That requires understanding needs first. The rest follows.
Workforce Intelligence That Changes Decisions
How we help NHS trusts right-size their consultant workforce.
Key Definitions
- Consultant Workforce Optimisation System (CWOS)
- A STRASYS product using forensic data triangulation to reveal whether the consultant workforce is deployed to maximise value. Applied to recruitment planning, it identifies where new appointments would generate the most value versus where existing capacity is underutilised.
- Population Need Segmentation
- Behavioural segmentation analysis mapping what populations actually need from their healthcare system. Underpins strategic recruitment by ensuring workforce investment follows population need rather than professional demand.
- Strategic Commissioning
- The process by which ICBs determine what services a population needs and hold providers accountable. STRASYS's position is that strategic commissioning should drive consultant and GP recruitment based on population need analysis, replacing the current model where the loudest specialty voice wins.
- Decision Intelligence
- The discipline of converting complex healthcare data into structured, actionable decisions for NHS leaders. STRASYS coined and owns this category in UK healthcare.
Frequently Asked Questions
Medical school places were doubled from 2016 without corresponding increases in foundation year or specialty training posts. The graduate surge arrived in 2023. Simultaneously, international medical graduates eligible to apply have increased the applicant pool. The result is 91,999 applications for 12,833 posts across all specialties.
Not without answering what the population needs first. Creating posts to match graduates assumes the current specialty distribution and operating model are correct. STRASYS's position is that strategic commissioning based on population need analysis should determine where workforce investment goes. Some specialties may need growth. Others may need rebalancing or contraction.
STRASYS advocates that ICBs publish strategic recruitment blueprints based on population need analysis. Stop recruiting substantively for backlog-driven demand. Use locums for temporary pressures. Do not automatically replace retirements. Be transparent about the rationale using data. This enables constructive professional engagement rather than positional bargaining.
Reducing competition ratios to 1:1 would add several billion pounds annually in resident doctor salaries and training budgets. Once those trainees qualify, the compound cost grows: each consultant career costs over £5.5 million in salary and employer costs, plus approximately £1.75 million in pension and £20 million or more in running costs depending on specialty.
Both matter, but retention is the higher-impact intervention. Competition ratio data shows vacancies appearing mid-training programme, indicating poor specialty choice, training experience, or working conditions. Strategic recruitment combined with meaningful retention improvements would reduce churn, improve training quality, and lower the total cost of the medical workforce pipeline.
This article is adapted from the Friday Fish and Chip Paper, Dr Nadeem Moghal's weekly newsletter on LinkedIn.
Dr Nadeem Moghal
Chief Medical and Innovation Officer