The F3 year: what is it and what are its implications?

Introduction

Only 43% of junior doctors entered straight into a UK specialty training programme after completion of their foundation programme in 2017, a substantial decrease from 71% in 2011.¹ Given the National Health Service in the UK is under ever-increasing workforce pressures, this is a worrying trend. The decline in entry to specialty training can be partly explained by the rise in what is known as ‘the F3 year’. Concerns over this ‘junior doctor exodus’ are not new, having been previously raised in 2010^2,3 when the figures were far more favourable than they are now. Similar trends can also be seen at earlier stages, with fewer school students applying to medical school, and fewer medical students applying to the foundation programme,⁴ indicating wider issues. To reverse this trend and the shortage of doctors in many specialties, solutions to encourage more foundation doctors to enter specialty training need to be considered.

Current data trends

According to latest figures from the foundation programme annual reports,¹ the proportion of post-foundation trainees entering specialty training has declined year on year, from 71% in 2011 to 64% in 2014, to now only 43% (Figure 1), with the remaining 57% going on to other destinations. The most concerning decline has been in those choosing a ‘core-training programme’ which make up the majority of training posts (core medical, surgical, psychiatry or general practice training), undertaken by 34% of foundation doctors in 2011, falling by almost half to 18% in 2016.

Figure 1.

The decline in proportion of doctors going straight into specialty training posts after completion of the foundation programme, from 71.3% in 2011, to 42.6% in 2017 (1).

Where are they going?

So where is this additional 25% of Foundation Year 2 (FY2) doctors over the last five years going, if not directly into specialty training? Around 14% (an increase from 2.3% in 2011 to 16.7% in 2017) have obtained a ‘service appointment in the UK’,¹ such as a National Health Service trust grade job, and 4% (an increase from 3% in 2011 to 7% in 2017) have an alternative appointment within the UK, such as a teaching fellowship. Interestingly, the proportion of those leaving the UK to work abroad remains largely unchanged (8% in 2011, dropping to 4% in 2014, returning to 8% in 2016 and falling again to 2% this year). Although small in absolute numbers, a concerning six-fold rise has occurred in the number of doctors permanently leaving the profession after the second foundation year (from 0.1% in 2011 to 0.6% in 2016). Finally, those not practising medicine after FY2, taking ‘a career break’, has increased substantially year on year from 4.6% in 2011 to 13.8% in 2017.

Why the decline?

The decline cannot be explained by a lack of available positions as the number of specialty training posts has increased in England since 2013.⁵ One reason for the decline is that many foundation trainees are unsure of their future career path in medicine, not wanting to commit to a training pathway very early in their career, apprehensive of choosing the wrong specialty. A contributing factor to this may be that specialty training applications occur early in the second foundation year. The rigid structure of specialty training has also been highlighted as a possible explanation.³ However, figures show the proportion of those choosing run-through training posts has remained stable since 2011 at around 33%. One study found that of those trainees not moving straight into specialty training, the most common reason cited was being unsure about long-term career plans (28%), followed by wanting to experience time abroad (24%).⁶ For trainees in a position of uncertainty, a flexible non-training post, in the form of a National Health Service trust grade job, or the equivalent outside of the UK, is an increasingly desirable option.

A potential cause for greater concern is the emigration of doctors, to Australia and New Zealand in particular, often highlighted in the media as a potential contributor to staffing shortages in the UK. It is not uncommon for trainees to take these opportunities after a natural break in medical training, attracted by new experiences, better pay and a better quality of life.⁷ However, available data suggest that the number of doctors of any grade leaving the UK has remained largely unchanged over the last decade.⁸ Similarly, specifically for those completing the foundation programme, the proportion of those moving to work abroad is the same in 2011 as 2016.¹

However, perhaps the most worrying trend is the increase in trainees wanting to take a post-foundation career break and in those leaving the profession altogether. Lambert et al. found that doctors surveyed three years after graduation were significantly more likely to cite factors related to the National Health Service, pay, working conditions, work–life balance and patient care as reasons for not remaining in the UK or in medicine.⁹ The increasing pressures on the National Health Service through chronic under-funding and a lack of hospital beds, and the subsequent pressures on the stretched junior doctor workforce have left many feeling disenfranchised. In England, the implementation of a new contract, and the bitter dispute that followed, may also have contributed to low morale among junior doctors.¹⁰ These factors undoubtedly contribute to the number of post-foundation doctors moving abroad, taking a career break or leaving the profession altogether.

Impact on the health service

So what impact does this trend have on the health service? This may just represent a growing trend towards taking a gap year at a natural break between training programmes, in which many doctors plan to return to specialty training at a later stage. Health Education England report that 90% of doctors return to specialty training within four years of completion of foundation training. However, despite the increasing number of specialty training posts, they are becoming increasingly difficult to fill, thereby resulting in a widening recruitment gap.⁴ This contributes to ongoing workforce issues within the National Health Service and worsening rota gaps,¹¹ putting junior doctors under increasing pressure. This leads to falling numbers of those seeking specialty training, compounding the problem. Only 79% of core medical training posts, 66% of core psychiatry training posts and 70% of general practice training posts were filled in 2016 after round 1.¹ This has a huge impact regionally, with the north of England experiencing the poorest fill rate of posts.⁴

Possible solutions

Work needs to be done to address this trend, which is showing no signs of reversing. The increasing numbers of those uncertain of which training pathway to apply for suggests a need for increased flexibility in training programmes, allowing doctors to try different specialties before committing to a training pathway. It may be difficult to reduce numbers of those moving abroad, but efforts could be made to ensure return of these doctors to specialty training in the UK, by ensuring working conditions in the National Health Service can compete with offerings from Australia and New Zealand. Most importantly, the ebbing morale of junior doctors needs to be resolved through increased funding of the health service and changes to health policy, to ensure favourable working conditions and a motivated National Health Service workforce.

Conclusion

There has been a worrying decline in the number of foundation doctors entering straight into specialty training posts. This may be explained by an increasing trend for a gap year or ‘F3 year’, in which trainees take the opportunity to experience another medical specialty or work abroad. However, it may be a sign that junior doctors are feeling increasingly disillusioned at a time when the National Health Service needs them most. Further investigation into the reasons why doctors choose to defer, and data on those that do eventually go on to specialty training in the UK, would shed some light on this increasingly important issue.

Declarations

Competing Interests

PJ is a Foundation Doctor working in the NHS. AM supervises foundation doctors undertaking placements in his department.

Funding

The Department of Primary Care and Public Health at Imperial College London receives support from the Northwest London NIHR Collaboration for Leadership in Applied Health Research and Care, the Imperial NIHR Biomedical Research Centre, and the Imperial Centre for Patient Safety and Service Quality. The views expressed in this publication are those of the authors and not necessarily those of the NHS, NIHR or Department of Health.

Ethics approval

Ethical approval was not required or sought in the writing of this article.

Guarantor

PJ.

Contributorship

PJ wrote the first draft of this article, which AM then edited.

Acknowledgements

None

Provenance

Not commissioned; peer-reviewed by Judy Wakeling and Yvette Pyne.