Thousands of doctors working for the NHS are trapped in unstable "gig-economy-style" contracts that deny them training, fair career progression, and national safeguards, raising serious concerns about long-term patient care and workforce stability. However, experts believe that with the correct reforms, the system can be fixed in ways that will ultimately improve patient care. 

A new study published in The BMJ finds that locally employed doctors (LEDs)—a rapidly rising group of clinicians, many of whom are international graduates—are engaged on local contracts that do not fall under national protections. LEDs are doctors who work directly for specific trusts rather than through nationally accepted training pathways. This implies that trusts can control their compensation, instructional time, hours, and supervision. 

Between 2019 and 2023, the number of LEDs in England and Wales increased by 75% to 36,831 doctors. According to Freedom of Information data received by The BMJ, nearly nine out of ten acute trusts continue to use old local contracts, some of which were written more than two decades ago but have not been amended to include precautions introduced in 2016. 

Although government guidance specifies that doctors should not stay on these contracts for more than two years, the BMJ discovered examples where professionals were locked in for a decade or more. Around a quarter of LEDs have now passed the two-year mark—and doctors from ethnic minority backgrounds are over-represented in this category. 

One surgeon with a degree from Southeast Asia stated that she had been on an LED contract for almost 17 years. "When she raised these issues with her line manager, she was told that she could either accept the situation or quit." A plastic surgery doctor described their position as "stagnant—no scope for growth..." We're basically plugging the gaps in the service delivery system here." A third LED stated, "I'm trapped in this LED contract." "It is so unfair." 

An overseas medical graduate from Pakistan stated that many trust grades had not received assessments in the past two years. We can't be stuck like this." 

Experts believe doctors are frequently unable to fight these terms due to visa restrictions, financial restraints, or family duties. Emma Runswick, Deputy Chair of the BMA Council, described the findings as 'more striking evidence of the way that locally employed doctors are exploited in a contractual 'wild west'.' 

Some argue that the NHS is now essentially "behaving like a gig economy employer." Partha Kar, a consultant endocrinologist, believes that every doctor should have systematic supervision and a clear way forward. Campaigner Rob Fleming believes LEDs should be placed on official SAS contracts to re-establish a feeling of professional identity. 

Government and NHS employers say LEDs are "highly valued" and that changes are coming through the SAS pay contract, but they admit that not all trusts are reaching expectations. 

Despite the crisis, many believe reform is still possible—and that reforming LED contracts would safeguard doctors and contribute to a more stable workforce. Finally, a more equitable approach could promote continuity of care, minimise burnout, and strengthen the NHS for patients who rely on it.