Almost 9 in 10 trusts use contracts that deny doctors training and fair pay progression
Experts warn that the NHS is effectively "behaving like a gig economy employer"
Thousands of locally employed doctors (LEDs) – many of them international graduates and from ethnic minority backgrounds – are trapped on insecure NHS contracts with no access to training, career progression, or national safeguards, reveals an investigation published by The BMJ today.
LEDs are the fastest growing group of doctors in the UK, driven mostly by those who graduated outside the UK. From 2019 to 2023, the number of LEDs in England and Wales rocketed by 75% to 36,831 doctors.
Freedom of Information (FoI) data obtained by The BMJ show that almost nine in 10 UK acute trusts use local contracts – some dating back as far as 2002 without safeguards introduced in 2016 – letting them set terms without guarantees on pay, hours, teaching, or supervision.
Although guidance states that doctors should spend no longer than two years on local contracts, The BMJ has found alarming evidence of senior doctors effectively stranded in these unsuitable contracts for 10 years or more.
Data gathered from FoI requests found that around one quarter of doctors on local contracts had been employed by their trust for more than two years. Doctors from ethnic minority backgrounds were more likely to be in this position, our data found.
One such doctor, a surgeon with a degree from South East Asia, told The BMJ that she had been on an LED contract for over 17 years. When she raised these issues with her line manager, she was told that she could either accept the situation or quit.
Another doctor working in plastic surgery in the North West on a trust grade registrar contract said: "This is a stagnant post-there is no scope for growth. That's the problem with the locally employed doctors-the local trust, they have their own rules, and we're just doing the gap filling role in the service delivery system here."
Another doctor who has been on a local contract since 2016 said: "I'm kind of trapped in this LED contract. It's been so annoying, and it's been going on for years. It's so unfair."
And an international medical graduate from Pakistan, working in Yorkshire on a local contract for more than two years, said: "Many of our trust grades have not had appraisals for the past two years. The trainees do get their appraisals. We don't have teaching opportunities, and we don't have time for learning. We can't be stuck like this."
Many of these doctors feel unable to challenge their employment status due to factors such as family responsibilities, financial pressures, visa constraints, career progression concerns, and the fear of uncertainty.
The BMA's deputy chair of council, Emma Runswick, describes The BMJ's findings as "further stark evidence of the way that locally employed doctors are exploited in a contractual 'wild west,'" with dire terms and conditions and a lack of clear development opportunities.
Others describe the situation as a "two tier system" for doctors in the NHS and warn that the NHS is effectively "behaving like a gig economy employer."
Partha Kar, consultant endocrinologist and former Royal College of Physicians elected councillor, wants to see a national framework that holds trusts to account. There should be no such thing as a non-training doctor, he says, and everyone should have access to clinical and educational supervision and the ability to progress their career.
A spokesperson for the Department of Health and Social Care says that LEDs are "an integral and highly valued" part of the NHS and that it is aware of reports from doctors that "trusts are not appropriately treating staff . . . This is completely unacceptable, and we are committed to improving working conditions through the implementation of elements of the SAS pay deal."
NHS Employers also says that LEDs are "valuable" to the NHS and should be supported to help develop their careers. But nationally agreed contracts, although recommended, are not always suitable, says its chief executive, Danny Mortimer.
Rob Fleming, specialist anaesthetist and member of a campaign group, the SAS Collective, says the NHS must be stopped from "behaving like a gig economy employer." He concludes, "We believe that locally employed doctors should be offered the appropriate permanent SAS contract for their work. As well as employment rights, this would give these folks the professional identity they are currently being denied."
