Is Scotland the best part of the UK to train as a doctor?

Is Scotland a more attractive part of the UK to train as a doctor?

Figures released on Tuesday reported that there were a record number of applications for medical training posts in Scotland last year, with 1,231 junior doctors at various stages taking up posts in specialties ranging from psychiatry to intensive care. This included 343 entry-level posts in general practice which, for the first time, had 100% fill rate.

So how does the experience of doctors-in-training here compare, and are we in the process of diverging even further from England?

Pay and strikes

In August 2023, junior doctors in Scotland called off a threatened strike after reaching a pay deal with the Scottish Government that included a 12.4% pay increase for 2023/24 and an agreement that salaries will increase at least in line with inflation over the following three years.

Meanwhile, junior doctors in England remain locked in a bitter stand-off with the UK Government despite months of industrial action, and junior doctors in Wales began a four-day walkout over pay on Monday.

According to a GMC survey, 85% of trainee doctors in Scotland were satisfied with their experience compared to a UK average of 82.3%.

Basic pay for a junior doctor embarking on specialty training is broadly similar, however, at just under £44,000 in England now compared to roughly £43,500 in Scotland.

So what else might set Scotland apart?

The PA row

One issue that has become increasingly toxic in recent months is the plan to boost physician associate (PA) numbers. These are mostly bioscience graduates or healthcare staff – such as nurses – who complete a two-year postgraduate course which enables them to work with patients.

While they do not hold a medical degree, and should not prescribe drugs or order X-rays, they are allowed to examine patients, make diagnoses, and development treatment plans subject to the supervision of a consultant or GP who is supposed to triage patients first – allocating only those patients considered to be low risk to PAs.

The UK Government has set a target to increase the number of PAs working in NHS England from almost 4000 currently to 10,000 by 2037.

Opposition is so fierce that it led the Royal College of Physicians in London to hold an emergency general meeting last week for only the third time in its 500-year history where members voted in favour of pausing the expansion. The whole process descended into rancour, however, amid accusations that the College (which is being paid to provide PA training and evaluation) had tried to conceal data showing that 40% of doctors who had a PA on their team felt they were not appropriately supervised.

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The Scottish Government is so far taking a more cautious approach. Giving evidence to MSPs in January, erstwhile Health Secretary Michael Matheson insisted that NHS Scotland would not replicate this "very rapid expansion". There were fewer than 150 PAs working in Scotland by the end of last year compared to more than 6,700 doctors-in-training.

The idea of a rapidly expanding PA workforce has angered medics for several reasons.

Already there are concerns that shortages of senior clinicians mean that PAs are sometimes working without proper supervision, going beyond their remit, or misdiagnosing patients who mistakenly believe they have seen a doctor.

There are also complaints that junior doctors are losing out on training time as consultants take on responsibility for PAs as well as trainee medics.

Unlike other healthcare professionals, PAs are currently unregulated. The GMC is in the process of taking on that role despite opposition from the BMA, which insists it will only muddy the waters further between medical and non-medical staff.

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There is also a financial gripe: the starting salary for a PA is around £44,000 compared to £33,000 for a medical graduate in their first year of foundation training.

For now, the Scottish Government's talk of a "gradual" increase in PAs is the less controversial path and one that, potentially, could increase the appeal of medical training north of the border.