Emergency departments are the NHS pressure gauge. When staffing is fragile, risk rises quickly: longer waits, delayed decisions, and the slow erosion of staff morale.

 

The GMC’s Workforce report 2025 does something unusually valuable: it doesn’t just tell you how many doctors exist.

It shows how specialties are being held up by different mixes of specialists, SAS doctors, and locally employed (LE) doctors, and it reveals that emergency medicine sits at one extreme.

 

In England and Wales in 2024:

• There were 1.4 LE doctors in emergency medicine for every specialist with an emergency medicine qualification.
• Emergency medicine also had the highest SAS ratio: 0.57 SAS doctors per specialist.

Those ratios are not just interesting. They describe the staffing model that patients experience every day.

 

Why ratios beat headcount in emergency medicine

Headcount tells you how many people exist in a system.

Ratios tell you how work is actually organised:

• how many senior decision-makers are available,
• how much service delivery depends on non-training roles,
• how supervision and escalation likely function.

The report’s ratio approach places LE and SAS numbers into the context of how many specialists exist in each specialty area. That’s vital because “more LE doctors” can mean two very different things:

• a planned, supported workforce with stable careers, or
• a fragile patchwork filling gaps that should be covered by senior staffing.

Emergency medicine’s ratios suggest the second risk is real, unless leaders actively build the first.

 

The contrast is stark: emergency medicine vs radiology/pathology

The report explicitly compares emergency medicine with specialties like radiology and pathology.

In 2024:

• Radiology and pathology had only 0.06 LE doctors per specialist.
• Their SAS ratios were also much lower: 0.04 (radiology) and 0.07 (pathology).

This contrast matters because it shows emergency medicine is not just “short-staffed.” It is structurally dependent on a different workforce tier and that should reshape how we talk about workforce resilience.

 

What emergency medicine’s ratios imply operationally

A high LE-to-specialist ratio suggests:

• large volumes of service are delivered by doctors who may not be in formal training
• supervision demand on specialists is high
• continuity is harder (LE posts can be fixed-term and churn-prone)
• staffing stability depends on whether LE and SAS doctors can build sustainable careers

A high SAS ratio can be protective, SAS roles are often more stable than LE roles, and the report shows SAS doctors are far more likely to have permanent contracts.

But the combination of very high LE and high SAS suggests emergency medicine is operating with:

• a constrained specialist base,
• a significant reliance on non-training service doctors,
• and therefore a heavy supervision and governance load on senior clinicians.

That is not inherently unsafe, many departments make it work.
But it is high-risk if not deliberately designed and supported.

 

The insecurity problem: emergency medicine relies on a workforce tier that is least secure

Part of the challenge is not just “how many LE doctors.” It’s how they are employed.

The report shows that among LE doctors in England and Wales in 2024:

• 76% are on fixed-term or fixed-term temp contracts
• 12% are bank
• only 9% are permanent

In contrast, 83% of SAS doctors are on permanent contracts.

So emergency medicine, the specialty with the highest LE ratio is also the specialty most exposed to the instability of LE employment models.

This is a structural mismatch:

• a high-intensity, high-risk clinical environment
• supported by a workforce tier with high contractual insecurity

That’s not a moral criticism of employers or doctors. It’s a design problem.

 

The international workforce dimension: emergency medicine is highly dependent on non‑UK doctors

Part 1 of the report explicitly flags emergency medicine as having “the highest proportion of non‑UK PMQ doctors” not only on the specialist register but also in SAS and LE roles working alongside specialists.

This makes emergency medicine uniquely exposed to:

• changes in international inflow,
• changes in training eligibility rules,
• and shifts in perceived progression opportunities for non‑UK doctors.

It also means policy rhetoric matters. The report’s foreword warns that doctors are mobile and may choose other destinations if they perceive progression barriers or a hardening of support.

Emergency medicine is exactly the sort of specialty where small shifts in retention can produce big operational holes.

 

The critical question: are LE roles in emergency medicine a pathway or a parking bay?

A ratio of 1.4 LE doctors per specialist could represent a robust model if LE doctors have:

• structured induction and supervision
• career development
• access to appraisal and revalidation support
• credible progression routes (including into training, SAS, or alternative senior pathways)

But if LE roles function as short-term “rota glue,” the model becomes:

• churn-heavy
• supervision-heavy
• and vulnerable to sudden recruitment shocks

The report doesn’t measure “pathway quality.” That’s the missing piece leaders need to add.

 

What leaders should do: make workforce architecture explicit

If emergency medicine is being staffed by this mix, the plan must match the mix.

Here are five concrete actions that align with the report’s evidence:

1) Convert “permanent reliance” into permanent roles

If LE doctors are a long-term structural component, keep fewer of them on fixed-term contracts by default. The data shows LE is overwhelmingly non-permanent, that’s a churn engine.

2) Strengthen SAS pathways in emergency medicine

SAS contracts are more stable. If the service relies on senior non-consultant decision-makers, design that workforce on purpose.

3) Reduce supervision overload on specialists

High LE numbers mean high supervision needs. Protect senior time for escalation, teaching, governance, and quality improvement, not just firefighting.

4) Build a credible bridge into training

Part 1 shows many non‑UK doctors aim for training and may work in locally employed roles for years before applying. If emergency medicine relies on them, it should be a place where progression is supported, not accidental.

5) Measure retention and continuity as safety metrics

If you don’t know your turnover rates in LE roles, you don’t know your operational risk.

 

Conclusion: emergency medicine is showing you the NHS’s real workforce design

The report’s ratios show that emergency medicine is being held up by LE and SAS doctors at unusually high levels.

That reality should change the conversation. The question isn’t “should this be the case?” It already is.

The question is: will leaders design safety and sustainability into that model or continue to run it as an unstable patchwork and hope it holds?

In emergency medicine, hoping is not a workforce strategy.

Source: GMC Workforce Report 2025