Dr Peter Prinsley

I absolutely agree that doctors are only part of a much bigger healthcare system. We certainly need to look after all the people involved in health and social care. Of course, that is more of a problem in geographically remote districts such as the hon. Gentleman’s constituency, where I believe it is difficult to recruit professions of all sorts. I do not want only to sound nostalgic this morning, although of course I am. I am not arguing that absolutely everything was better in my time, because it certainly was not, but in one important respect it was better: it was designed around human beings. It understood that newly qualified doctors are individuals, not one of a herd to be simply moved across a map by a computer. It also recognised that pastoral support and clinical teams matter, and that the transition from medical student to doctor is a particularly vulnerable moment in a medical career. Let us come back to that point soon. Today, we have a thing called the foundation programme. In 2024, the foundation programme office replaced the application process with something called preference informed allocation. What happens is that medical students list the foundation schools in order of preference, and are each assigned a computer-generated rank. The rank is not informed by academic achievement, personal circumstance, where the student trained or what they did; it simply works through the ranks and places the student accordingly. The UK foundation programme’s 2026 figures show that of the 10,810 graduates allocated this year, 82% received their first preference. Superficially, that sounds quite reassuring, but I do not really think it is. Every year, a minority of graduates—this year it is roughly 1,900 young doctors—end up somewhere other than their first choice. The minority who do not get their first preference find themselves, aged 22 or 23, packing up their lives for a city where they know nobody. As I put it in the Chamber last month, it is a “crazy foundation lottery that sends a doctor from Norwich to Belfast and a doctor from Belfast to Norwich.”—[Official Report, 26 March 2026; Vol. 783, c. 452.] That is what we mean when we talk about a lottery. It is not a figure of speech, but a literal description of how the system works. There is another reason why this headline figure flatters to deceive: the system incentivises what we call strategic preferencing. The students know the ranking system is random and that a high rank does not protect them tomorrow, so they game it. They preference the foundation schools they think they can realistically get, rather than the ones they actually want. A high first preference rate is, in part, a measure of the student lowering their ambition to protect themselves against a coin toss. That is not a system working; that is a system being worked around. Let me say a bit about couples. Medical students often form a couple with other medical students or other people who work in hospitals, because that is the nature of a hospital. The foundation programme offers something called linked applications, but the unfairness is particularly acute. Two medical students in a relationship can choose to link their applications so that they are allocated together, but the pair is placed using the lower of the two ranks, so that if one of them is lucky in the ballot and the other is not, both are placed in the worst ranked situation. Should the algorithm be unable to accommodate both in a single school, the link is broken. A student cannot unlink once they have applied, and there is no appeal. The system quite simply cannot see that these are two people trying to begin their careers side by side. It just sees two records on a database. That has knock-on consequences throughout the rest of the service. When foundation doctors are disorientated, unsupported and demoralised, their work does not disappear; it flows upwards to the more senior doctors, who take more and more of it on themselves. Young doctors should not be deployed by ballot into strange cities, with only limited account taken of their circumstances—their partners, their dependants, their health or their need to be near home. The claim that the current system is somehow fairer than the one it replaced is, I am afraid, one we cannot accept. Let me talk about how we got here and the recent reform. The old system was not perfect. For many years, medical students competed on a combination of academic decile and a national examination known as the situation judgment test. The SJT was quite unpopular: it was stressful, it had unpredictable validity and there was a documented score gap that consistently disadvantaged candidates from ethnic minority backgrounds. That was a real and serious unfairness, and those who reformed the system were right to try to address it. When the students lobbied against the SJT, they had a good reason to do so, but they did not ask for a random number generator—yet that is essentially what they got. In 2024 the SJT was abolished and academic achievement stripped out. In their place came PIA, underpinned by a computer ranking. It is hard to think of a clearer case of throwing the baby out with the bathwater. Students asked for fairness, and they were given randomness. Those are not the same thing. Fairness takes account of circumstance; randomness ignores it. Fairness rewards merit and responds to need; randomness does neither. What we have is not a reformed system, but an experiment that has gone wrong. That is not just my view. The medical training review led by Professor Stephen Powis and Professor Chris Whitty, published last October, drew on more than 8,000 responses, 6,000 of them from resident doctors. Its very first recommendation was that “a reform of postgraduate medical education and training is undertaken as a matter of urgency.” It also recommended that recruitment to medical training be reviewed so that it is “fair and equitable to all candidates”. It is not sufficient, on any reading of the report, for allocation merely to be random. Random is not fair. The BMA has taken a big interest in this question, which is not surprising, and I will read out some of its recommendations: “The BMA is calling for: meaningful improvements to working lives with greater access to support services, supervision, rest and mess facilities; increased flexibility in rotations, including the option to swap placements; a guarantee that all UK graduates will be offered a foundation post, with full details provided at least 12 weeks before the start date; and any review of the allocation system to include proposals for a new recruitment process developed with meaningful consultation with students.” There is another group of doctors that we should consider: those who will progress to become academic doctors. There is a crisis in this country of clinical academics, the doctors who teach the next generation of doctors. It has become very difficult to recruit into clinical academia. The career pathway for clinical academics has become very uncertain, and we have an emerging crisis—a real and present crisis—that must be addressed. One way to do that is to think about how we recruit foundation doctors into academic programmes. Here is a straightforward proposal, which I hope colleagues will improve rather than simply accept. Let us return to a firm-based model for the first year of training. The F1 placement should be arranged by the medical schools, not by a centralised national algorithm, with each new doctor placed alongside peers they already know with consultants who have taught them. That is the system we had so many years ago. Medical schools know their students; they know who has the caring responsibilities, who has a linked partner, who has health needs, who has a strong reason to stay close to home. They are in the best possible position to start designing a year that makes sense for each individual. That does not preclude movement later. F2 can broaden horizons, and specialty training will often mean relocation, but in the critical first year, when doctors are doing their first on-calls up at night by themselves, writing their first prescriptions and being present at their first deaths, they should not be alone in a city where they do not know anybody. They should be doing that with the support of their friends, teachers and colleagues they already trust. I do not think that would be particularly expensive; it might even cost less than the centralised allocation machinery we run today. Whatever we do, I offer one principle: medicine is the most distinctly human of professions and it is futile, and somewhat ironic, to try to reform it with an algorithm. The reform must be human. Let me close where I began. Resident doctors have just come off picket lines. I do not think that in this debate we can rehearse the pay dispute, which is a matter for another day, but the strikes are not just about pay. At root, they are about a sense that the profession has been treated as though it does not matter. The individual doctor has become invisible behind the workforce spreadsheet. The Government have taken one very important step, with the Medical Training (Prioritisation) Act 2026 giving UK graduates the rightful priority for specialist training places—and that matters. Today’s debate is an opportunity to take the next step to fix the starting point itself. We have in medicine one of the most extraordinary workforces in the world. Young doctors are among the best trained, most dedicated and most compassionate professionals. We owe them and, more importantly, the patients who depend on them, better than a lottery. We owe them the fair, well-supported, human start they deserve. I believe that would go a long way to resetting the Government’s relationship with the profession, and towards ending these damaging rolling strikes.