DoctorInTheUK
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NHS Structure
OVERVIEW
The general pathway is starting out as a foundation doctor, then specialising and finally becoming a consultant. Foundation training is 2 years long while specialty training ranges from 3 years (for GP) to 8 years (for many hospital-based specialties). Additional training after reaching GP or Consultant status is optional. Remember that all training posts are paid in the UK, so you will be working as a doctor every step of the way.
There are several ways to walk this path and it can be confusing in the beginning, especially for an outsider.
So let’s begin to explore each step.
The Structure
Training is organised in 3 levels: national, regional and local.
The local level is made up of hospitals. On the regional levels they are grouped into deaneries or LETBs (Local educational training boards). On the National level there are several organisations such as Health Education England (HEE), NHS Education for Scotland, NHS Wales Shared Service Partnership, Northern Ireland Medical and Dental Training Agency, and the Royal College of each specialty.
Once you are recruited by a hospital, you are appointed to a place of training run by a Local Education Training Board (LETB) or deanery. Health Education England (HEE) hosts the LETBs for England. Wales and Northern Ireland and Scotland host their own deaneries.
Here’s a link for 8 organisations you’ll encounter as a doctor in the UK at some point in your training. It is good to be familiar with them but don’t be overwhelmed; you will get to know them as soon as you start your foundation training.
The Pathway
Crossing the finish line in the UK training race means that you either become a Consultant (you become part of the Specialty Register of the GMC) or a GP (General Practitioner Register of the GMC). Depending on the specialty you choose there are specific ways to reach this goal.
FOUNDATION YEARS
First, you need to attain a Certificate of Completion of the Foundation Programme (CCFP). There are 3 ways to do this:
- 1. Complete the 2 years of the Foundation Programme with all the requirements outlined each year. This is ONLY if you are eligible for a provisional registration.
- 2. Complete 1 year of FY2 Stand-alone. This is ONLY if you are eligible for a full registration.
- 3. The third way to get the CCFP is to work as a non-training doctor in various rotations and then have your educational supervisor assess your progress and competencies. They can then complete a form of equivalence, which means that you have attained all the required skills of an FY2 doctor and would be eligible to apply for specialty training. This may take less, more or the same time as a foundation doctor would take. By working as a doctor outside of the foundation programme (that would be usually a Trust grade position) you are not officially in training, so you need to have someone supervising you and making sure that you tell them that your goal is to attain this certificate of equivalence so they can guide you appropriately.
In terms of supervisors, you will have a clinical supervisor (CS) for each rotation you undertake and an educational supervisor (ES) for each year of training. They are both consultants. The CS is a consultant from the department you would be working in and they would guide you more closely and monitor you on a daily basis. The ES can be a consultant from any department in the hospital, not necessarily one you will be working in. The ES will help you with your portfolio, your overall plans and will be overseeing your progress.
Tip: When choosing between available positions, it would be smart to pick rotations that are relevant to the specialty you wish to pursue (if you already know what you want to do).
For all up-to-date information regarding the foundation programme and how to apply for it visit their official website.
SPECIALTY TRAINING
Specialty training in the UK is the same thing as residency in other countries. As you know there are various options and some specialties (residencies) have a different pathway that you should be aware of from early on. Here’s how it goes.
If you wish to do Cardiothoracic surgery, Neurosurgery, Obstetrics & Gynecology, Ophthalmology, Pediatrics, Radiology or GP then you have chosen a so-called run-through or coupled specialty. What does this mean?
Run-through specialties
You go through the 2 years of Foundation Programme and/or once you get your CCFP you apply for the specialty you want directly. If successful, you get a national training number, often referred to as a “number”. You then progress through your years of specialty (ranging from 3-8 years, depending on the specialty), without having to re-apply for a position. Bear in mind, run-through specialties are usually very competitive. You also need to pass certain exams before progressing from one year to the next. For example, in neurosurgery you need to pass both parts of the (MRCS exam Member of the Royal College of Surgeons Part A & B) before progressing to ST3. To get an idea of the competition, most candidates pass their MRCS during their foundation years.
Un-coupled specialties
After the 2 years of foundation and/or once you get your CCFP you apply for core training. That is either core surgical training (CST) for most surgical specialties (except for the run-through ones outlined above) or internal medical training (IMT) for most medical specialties (except for the run-through ones). CST lasts for 2 years and IMT for 3 years in total. IMT replaced CMT (Core medical training) in August 2019. Once these 2-3 years are complete you have to re-apply for a higher specialty training position to become a registrar. The higher specialty training posts are limited and often competition is fierce. The main difference between coupled and un-coupled specialties is that you need to apply two times for the latter.
Acute Care Common Stem (ACCS)
For those of you who wish to enter higher specialty training in General Internal Medicine, Acute Internal Medicine or Anesthesia there is an alternative: the ACCS. This is a 3-year training programme that replaces IMT before applying to the afore-mentioned specialties. Important note: If your passion is Emergency Medicine (EM), then ACCS is the only core training programme before you enter higher specialty training in EM.
You go through the 2 years of Foundation Programme and/or once you get your CCFP you apply for the specialty you want directly. If successful, you get a national training number, often referred to as a “number”. You then progress through your years of specialty (ranging from 3-8 years, depending on the specialty), without having to re-apply for a position. Bear in mind, run-through specialties are usually very competitive. You also need to pass certain exams before progressing from one year to the next. For example, in neurosurgery you need to pass both parts of the (MRCS exam Member of the Royal College of Surgeons Part A & B) before progressing to ST3. To get an idea of the competition, most candidates pass their MRCS during their foundation years.
Un-coupled specialties
After the 2 years of foundation and/or once you get your CCFP you apply for core training. That is either core surgical training (CST) for most surgical specialties (except for the run-through ones outlined above) or internal medical training (IMT) for most medical specialties (except for the run-through ones). CST lasts for 2 years and IMT for 3 years in total. IMT replaced CMT (Core medical training) in August 2019. Once these 2-3 years are complete you have to re-apply for a higher specialty training position to become a registrar. The higher specialty training posts are limited and often competition is fierce. The main difference between coupled and un-coupled specialties is that you need to apply two times for the latter.
Acute Care Common Stem (ACCS)
For those of you who wish to enter higher specialty training in General Internal Medicine, Acute Internal Medicine or Anesthesia there is an alternative: the ACCS. This is a 3-year training programme that replaces IMT before applying to the afore-mentioned specialties. Important note: If your passion is Emergency Medicine (EM), then ACCS is the only core training programme before you enter higher specialty training in EM.
ANY QUESTIONS?
The Terminology
- Doctor: Generally speaking, when you graduate from a European medical school you are considered a doctor and can start practising. In the UK, this would translate to you having a full registration as a doctor and license to practice medicine (this is provided by the General Medical Council). UK medical school graduates are doctors who gain a license to practise medicine but provisional registration. Full registration is granted after Foundation Year 1 is successfully completed. To make sure you are eligible for a full registration and license to practice medicine in the UK, you need to visit the GMC website.
- Foundation programme (Stand-alone or 2 year): Lasts for 2 years, you are either an FY1 or FY2 (Foundation Year 1 or 2) doctor. The 2-year Foundation Programme is generally reserved for UK graduates, as you must be eligible for a provisional registration if you apply for this programme. Being a European medical school graduate, you will be eligible for a full registration which allows you to apply for a Stand-alone FY2 position*. You will be doing the exact same job FY2 doctors in the 2-year programme and you will have the same training requirements. Stand-alone means that you apply for each year separately, although personal experience has shown us that often when you are recruited for a Stand-alone FY1 you will be automatically offered an FY2 position at the same hospital.
* Previously, Stand-alone FY1 positions were available and medical school graduates with full registration had a chance to apply to these posts. Currently, the UKFPO have no plans to recruit to FY1 Stand-alone posts. If a doctor has full registration, they can check their eligibility to apply directly for an FY2 Stand-alone programme.
- Academic Foundation: This is a great option for people who want to gain more publications and be more active in the field of research. An academic foundation doctor typically has one out of the 3 rotations of the year that is dedicated to research.
- SHO: An SHO is a Senior House Officer. Practically anyone above an FY1 and below a registrar could be considered a senior house officer. It is a rough indicator of position within the rank but not a job title on it’s own. It comes from the previous organisation of the system which separated pre-registration house officers (currently FY1s) and senior house officers (currently FY2-3). Now an SHO could mean an FY2, CT1, CT2, ST1 or ST2. ST3 and above are registrars until the end of their specialty training.
- FY3: A foundation year 3 doctor is also not an official position. More and more doctors are deciding to take a year out of training after completing FY2, in order to strengthen their portfolios or take a trip or decide what specialty to follow. This is referred to as FY3.
- Back of house (BOH) & Front of house (FOH): You will hear this often in UK hospitals. Back of house doctors are covering the wards in the non-acute specialties. Being a back of house doctor also has implications on your rota. This means that you are not likely to have night shifts or long days very often or sometimes not at all. Front of house doctors are the ones working in A&E, Acute Medical Unit and General Surgery. Rotas can get more hectic in these positions as you will be in the “front line” of the hospital, often being the first to see a patient as they come in. As a foundation year doctor, you are most likely to have rotations that are both BOH and FOH.
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Non training positions:
- Trust grade doctor: A trust doctor or trust grade doctor is a doctor that works in the NHS in a non-training position, usually at the level of an SHO.
- Locum doctor: Working as a locum doctor means you can pick up shifts that are available in a particular department, whenever you decide to do so. You are not on a full-time schedule and you can have a more flexible working scheme.
- Core trainee: A core trainee or a CT can either be a CMT (Core Medical Trainee) or CST (Core Surgical Trainee), depending on their career path. Core training lasts 2 years and it is mandatory before all specialties except for the run-through specialties. Often just CT is used instead of CST or CMT. So once you start your core training you become a CT1 then progress to CT2 and then you have to apply for a specialty training position. The first year of your specialty training would be then ST3. ST1s & ST2s are those trainees that are going through a run-through specialty. So, for example, a pediatrician (run-through specialty) would go from ST1 to ST8 while a cardiologist would go from CT1-2 to ST3-7 (2 years of core medical training + 5 years of specialty training).
- Registrar/ Specialty training (resident): Specialty training doctors or registrars are referred to as ST + the year of training which they are in. So an ST4 would be in their fourth year of training and so on.
- Consultant: Pretty self-explanatory, no abbreviations for consultants. Just make sure you refer to all medical consultants as Dr and all surgical consultants as Mr or Mrs/Miss/Ms. It can be confusing but basically, in the UK, if you want to be a surgeon you transition from Mr as a non-doctor, to Dr after your graduate and during your training, to end up as Mr again! It’s an old British tradition, stemming from the Middle Ages, and most consultants won’t mind whatever you call them but you may come across a few surgeons who will insist on Mr or Miss. If you want to know the full story (and want to take a break from this confusing terminology) you can find it here: here (click me).
Other Resources
For more detailed information on the various roles of doctors in the NHS and how it works, we would recommend this website, which is addressed to international medical graduates mostly but a lot of it applies to European medical graduates too:
How specialty training (residency) works in the UK: A complete beginner’s guide