Flexible training has matured

Authors: Melanie Jones, Jane Montgomery, Sarah Thomas 

Publication date:  10 九月 2008

Jane Montgomery and colleagues give an update on less than full time training in the UK and report on 2007 recruitment

The need for doctors to train part time was recognised and the original scheme was introduced in 1969.[1] Less than full time (LTFT) training, also known as flexible training, has continued to develop and expand in recent years.

In 2005 the BMA reached agreement with the Department of Health and Conference of Postgraduate Medical Deans on new arrangements for flexible training.[2] This agreement confirmed the UK eligibility criteria for LTFT training (see box).

Category 1

  • Disability or ill health (this may include in vitro fertilisation programmes)

  • Responsibility for caring for children (men and women)

  • Responsibility for caring for an ill or disabled partner, relative, or dependant

Category 2

  • Unique opportunities for their own personal professional development (for example, training for national or international sporting events) or short term extraordinary responsibility (such as a national committee)

  • Religious commitment—that is, involving training for a particular religious role which requires a specific amount of time commitment

  • Non-medical professional development such as management courses, law courses, fine arts courses, or diploma in complementary therapies

Also outlined within the 2005 agreement were underpinning principles. Flexible training will be integrated into mainstream full time training in the following ways:

  • Use of slot shares and the continuing development of this system into a wider view of training opportunities, in terms of whole time equivalents, which can be filled by any combination of flexible and full time trainees

  • Development of permanent flexible posts in specialties and trusts or equivalent bodies where numbers allow it

  • Guaranteed equality of access to study leave, out of hours working, and all other employment rights and protections. In particular, the right of timely return to appropriate work from maternity leave will be respected and promoted.

One criticism of arranging LTFT posts has been the time taken to get approval and secure additional funding. Slot sharing uses less funding and does not need additional approval as the slot to be shared is already approved. The development of slot shares has progressed over the past three years and is extremely successful in many parts of the United Kingdom (see case history 1).

Case history 1

Dr A was a year 3 specialist registrar in learning disability psychiatry working LTFT in a deanery funded supernumerary post from January 2005. Dr B, another specialist registrar in the same specialty, requested LTFT in late 2006. After discussion with their supervising consultants and the employing trust, Drs A and B shared the out of hours component of Dr B’s full time slot and each undertook an individually tailored LTFT daytime programme, which also enabled service needs to be met. As funding from Dr B’s slot was used to pay both doctors (with a small additional top-up from the deanery) and a supernumerary post was no longer required, deanery funds could be diverted to support other new LTFT applicants.

Dr A returned to full time training in May 2007 and was replaced in the slot share by Dr C, who had a family emergency and wished to reduce her hours. Dr A wrote to the deanery: “Thank you so much for giving me the opportunity to train flexibly, it has meant I could spend extra time with my daughter in her early years and still progress in my chosen career.”

In Scotland slot sharing has been equally successful, with 10 paediatric registrars sharing five whole time equivalent slots and 10 anaesthetic specialty registrars filling six whole time equivalent posts. In Yorkshire and the Humber up to a third of paediatric trainees are training part time in slot shares. There are few reported difficulties associated with these arrangements once the service adapts to more staff working fewer hours. In Wales fixed flexible specialty registrar posts have been established in anaesthetics.

Increasingly, doctors wishing to work less than full time are accommodated, with the agreement of the employer, deanery, and specialty programme director, using modified established full time training posts—again ensuring further mainstreaming of LTFT training. As the hours of full timers are reduced and alternative working patterns are developed, the ability of the NHS to support doctors who request a reduction in hours has been met within their own programme rather than requiring the creation of supernumerary posts.

Historically the request for LTFT training was made after appointment to a post to avoid discrimination during the selection process. Inevitable delays in accessing LTFT training were experienced with this process, leading to some dissatisfaction.

In 2006 concerns were raised about the numbers in LTFT training and access to training posts of this nature. The numbers of those in LTFT posts declined in 2006 and this was thought to be the result of concerns about the introduction of run-through training and pressure on budgets of NHS trusts. The most recent survey by the Conference of Postgraduate Medical Deans in 2008 indicates that the total number in LTFT training has once again increased and is currently at its highest level—5.7% of all trainees (fig 1). The number of doctors in LTFT training has increased 461% since 1994, almost fivefold.

Fig 1 Total number of LTFT trainees from 1994 to July 2008

In 2007 the online system of the medical training application service enabled those who wished to train on an LTFT basis to indicate this at the time of application on the confidential section of the application form. Those concerned with selection remained blind to the candidate’s wishes, thereby ensuring equal opportunity for full time and part time applicants. Using the medical training application service system deaneries could predict demand for LTFT training. After completion of the selection process, new appointees were accommodated in slot shares with minimal delay.

Deaneries worked together to ensure a consistent approach to eligibility assessments, thereby minimising delay in access to LTFT training. Each trainee needed to complete only one eligibility assessment process as part of the national application process. Although the Tooke review criticises aspects of Modernising Medical Careers and the medical training application service it fails to mention the benefits of the consistent coordinated national process for LTFT training.

In round 1 of recruitment in 2007, 859 applicants indicated a desire to train LTFT (2.5% of the 33 779 applicants), and of these 376 were appointed. As each candidate could make up to four applications this indicates that candidates wishing to train on an LTFT basis were as successful in the selection process as their full time colleagues.

When appointment panels remain blind to the planned work pattern of the applicant, this has no influence on the appointments process. This can be considered to be an example of best practice in employment practice.

While most LTFT trainees are women with childcare commitments, 4% of LTFT doctors are men (fig 2). This increased demand from men for LTFT training may be the result of changes in work-life balance and the current approach to parenting (see case history 2).

Fig 2 Gender division of LTFT trainees from 2003 to July 2008

Case history 2

Dr X was a senior house officer in basic surgical training. He had a young child who was living with his expartner, the child’s mother. He applied for LTFT training, fulfilling the eligibility criterion 1, domestic commitments. He successfully competed for specialty training in trauma and orthopaedics on merit and has completed the specialty training programme to certificate of completion of training, working 60% of full time. He explained that he would have found it impossible both to train full time in trauma and orthopaedics and to maintain reasonable contact with his child.

“I could not have achieved this and the relationship I now have with my son if I had been training full time. I believe I would not be on the specialist register today if I had trained full time and did consider leaving hospital medicine in the early days. I know there is massive prejudice against part time trainees so even if training is completed there is a huge price to pay when applying for consultant jobs.”

Eleven per cent of LTFT doctors are those with personal health problems being supported to remain in the workforce by either short term or long term LTFT training programmes.

There are specialty and regional variations and work is ongoing to develop access and support those who wish to train on an LTFT basis. Deanery representatives meet regularly with the royal college leads for flexible training, the BMA junior doctors committee, and the Medical Women’s Federation.

The continued growth in LTFT numbers indicates the success of these programmes and the ongoing need for a process which will support the predicted increase in demand from young doctors in training. It is anticipated that the 2008 recruitment round will once again see a rising number of applications from those who wish to train LTFT and the deaneries and employers providing them with the opportunity to do so.

In future there will be a growing percentage of women within the medical workforce as a result of demographic changes in UK medical graduates and the increasing proportion of women undergraduates.[3] [4] The percentage of women doctors in the higher grades will also increase (fig 3).

Fig 3 Gender and grade of medical workforce in England 2006

Many of these doctors (both men and women) may wish at some stage in their careers to train and work part time.[5] [6] [7] The impact of the European Working Time Directive and the reduction of junior doctors’ hours have not led to the predicted reduction in demand for LTFT training; in fact, current evidence suggests that the introduction of shift working is driving demand as trainees struggle to balance shift working with family life. The revised training curriculums are competency based rather than time served. Those training less than full time have the opportunity to demonstrate the acquisition of competencies without necessarily doubling their training time.

The challenge for the NHS and for the medical profession will be to accommodate those who wish to train and work part time, ensuring they are retained within the profession.[8]


  1. Department of Health and Social Security. Re-employment of women doctors.   Health memorandum, HM (69) 6. London: HMSO, 1969.
  2. NHS Employers 2005. [Link]
  3. British Medical Association. The demography of medical schools: a discussion paper  . London: BMA, June 2004. [Link]
  4. .Medical Schools Council. Women in clinical academia: Attracting and developing the medical and dental workforce of the future. A report by the Medical Schools Council  . London: Medical Schools Council, 2007.
  5. .Lambert TW, Goldacre MJ, Turner G. Career choices of United Kingdom medical graduates of 2002: Questionnaire survey. Med Educ  2006;40:514-21.
  6. Saalwachter AR, Freischlag JA, Sawyer RG, Sanfey HA. The training needs and priorities of male and female surgeons and trainees. J Am Coll Surgeons  2005;201:199-205.
  7. Allen I. Women doctors and their careers. What now? BMJ   2005;331:569-72.
  8. British Medical Association Equal Opportunities Committee. Career barriers in medicine: Doctors’ experiences  . London: BMA, 2004.

Melanie Jones associate dean  Wales
Jane Montgomery associate dean  SE Scotland
Sarah Thomas postgraduate dean and chair of Conference of Postgraduate Medical Deans working group for LTFT training  Yorkshire and the Humber Deanery


Cite this as BMJ Careers ; doi: