If you listen to workforce debate in the UK, you might think the medical workforce is basically three groups: consultants, GPs, and trainees.

The GMC’s Workforce report 2025 makes it impossible to keep telling that story. In 2024, 87,151 licensed doctors were on neither the GP nor specialist register and not in training.

That is not a rounding error. It’s a major segment of the workforce and it is increasingly central to how services are staffed, how rotas are held, and how patient care is delivered across specialties.

This blog explains what the report shows about this group, why it matters to safety and sustainability, and what leaders should do differently if they want a workforce plan that matches reality.

 

First: who are “doctors on neither register, not in training”?

The report describes this as a diverse group, spanning:

• early career UK graduates (including those taking time out after F2)
• recent international joiners
• doctors with many years of experience who work in one specialty area but are not on the specialist register
• locally employed (LE) doctors
• SAS doctors (specialty and associate specialist)
• doctors in roles with consultant contracts (not on the specialist register), in specific circumstances

This group is often “in plain sight” in hospitals: they staff wards, night shifts, specialties under pressure, and service delivery that cannot be left to trainees alone.

But they are frequently undercounted in mainstream narratives because they don’t map neatly onto familiar professional categories.

 

The England & Wales lens: job role breakdown reveals scale and insecurity

The report uses NHS contracts data (limited to England and Wales) to segment doctors in this group more precisely.

In 2024, there were 66,292 doctors on neither register and not in training in England and Wales (within the broader UK-wide 87,151). Among this England/Wales group:

• 58% held a locally employed (LE) doctor contract, 38,394 doctors
• 19% were on a SAS job role, 12,577 doctors
• 7% held a consultant contract while not being on the specialist register, 4,670 doctors
• 16% had no NHS contract data, 10,651 doctors

Even without overinterpretation, this tells you something critical:

The NHS is being staffed at scale by doctors whose roles are structurally outside training and outside the specialist/GP register framework.

That is not a temporary phenomenon. It’s a workforce model.

 

International doctors are disproportionately represented across these roles

The report also shows that in 2024, all of these contract types had more non‑UK than UK PMQ doctors.

The most striking figure: among those on consultant contracts but not on the specialist register, 85% were non‑UK PMQ. SAS doctors were 81% non‑UK PMQ, and LE doctors were 69% non‑UK PMQ.

This is not about whether international doctors “should” be in these roles. It’s about recognising what the data implies:

• international doctors are sustaining core service delivery,
• often in roles with less security and less structured progression,
• and any policy that reduces international inflow or progression will hit the “hidden workforce” first.

 

The post-foundation reality: the LE workforce is also “home-grown”

There’s another reason the LE workforce is growing: UK graduates spending longer outside formal training.

The report notes that 12,755 doctors who were in F2 between 2012 and 2023 were licensed in 2024 but had not moved into specialty or core training thereafter.

It also states that the post-foundation LE doctors group has become larger than all specialty groups except surgery and the broad “medicine” umbrella group.

That is a major structural shift in early-career medical pathways and it has implications for supervision, wellbeing, and retention.

It also undermines the simplistic idea that LE work is only an “international doctor” phenomenon. The data suggests it’s becoming a mainstream pathway for many.

 

Employment conditions: LE is the least secure part of the model

Perhaps the most operationally important section of Part 2 is where the report compares employment types.

Among 38,353 LE doctors in England and Wales in 2024:

• 76% were on fixed term or fixed term temp contracts
• 12% were bank (only)
• 3% were locum (only)
• 9% were on permanent contracts

In contrast, among 12,575 SAS doctors:

• 83% held a permanent contract

The report calls the difference “stark” and explicitly states: LE is less secure employment, with 91% of contracts not being permanent.

This is a workforce planning issue, a morale issue, and a patient safety issue, because insecurity drives churn, churn drives discontinuity, and discontinuity drives risk.

 

Why this matters: you cannot build stability on perpetual temporariness

The data invites a hard question: what does a workforce plan mean if a huge and growing share of doctors are in insecure, non-training, non-register roles?

Leaders often treat LE roles as “flexible.” But flexibility and insecurity are not the same thing.

A sustainable workforce needs:

• predictable career progression routes
• stable employment frameworks
• fair access to development and appraisal
• safe supervision ratios
• consistent induction and governance

The report does not provide all those design answers, but it does provide the justification for asking the question urgently.

 

The critical interpretation: this is the NHS’s “shadow training pipeline”

One of the report’s clearest messages (across Part 1 and Part 2 together) is that the UK workforce increasingly functions like this:

• Many doctors (especially non‑UK PMQ, but also many UK PMQ post-F2) work in LE roles
• They then apply to training later and non‑UK doctors often do so after several years in LE work

If training becomes harder to access (for anyone), the LE workforce grows.

If training becomes less realistic for non‑UK doctors, the UK may lose international applicants who were motivated by the chance of progression and that could shrink the LE workforce too, because many join the system through that pathway.

So the LE/SAS workforce is not separate from the training system. It is part of the system’s pressure valve.

 

What leaders should do: treat LE and SAS as core workforce strategy

If your organisation relies on LE doctors to keep wards safe and rotas covered, you need to stop managing them like temporary gaps.

Three actions the report’s data strongly supports:

1) Build structured LE pathways with progression

Create clear job families: entry LE → development LE → senior LE, with defined expectations, supervision, appraisal, and access to training opportunities (including CESR routes where appropriate).

2) Reduce avoidable insecurity

A workforce with 76% fixed-term LE contracts is a workforce designed for churn. You don’t remove flexibility by offering more permanency; you remove fragility.

3) Align workforce governance with reality

If a large part of your service is delivered by doctors outside formal training programmes, your quality improvement, safety, and supervision structures must explicitly include them, not treat them as peripheral.

 

Conclusion: you can’t “fix training” without fixing the hidden workforce

The report’s numbers are a warning and an opportunity.

They warn that a huge part of the workforce sits outside familiar planning categories and often in insecure employment. But they also offer an opportunity: if leaders design better structures for LE and SAS roles, they can improve retention, continuity, and patient safety and reduce the workforce anxiety that comes from a system where too many doctors feel they are in limbo.

The hidden workforce is not hidden anymore. It’s the model.

Source: GMC Workforce Report 2025