Thousands of UK doctors trapped in NHS gig economy contracts, investigation reveals
A BMJ investigation reveals almost nine in 10 NHS acute trusts use local employment contracts that trap thousands of doctors – predominantly international medical graduates and ethnic minorities – in roles lacking training opportunities, career progression, and nationally agreed safeguards. Some doctors remain in these precarious positions for over a decade.
Investigation exposes “contractual wild west” in NHS employment practices
An investigation published in The BMJ on 19 November 2025 has exposed widespread exploitation of locally employed doctors (LEDs) across the NHS, with freedom of information data revealing that 156 of 179 responding acute trusts (87%) employed doctors on local contracts in 2024. These arrangements allow trusts to set employment terms without guarantees on pay, hours, teaching, or supervision – conditions experts warn mirror gig economy practices typically associated with precarious platform-based work.
The investigation found that LEDs represent the fastest growing segment of the UK medical workforce. Between 2019 and 2023, the number of LEDs in England and Wales increased by 75% to reach 36,831 doctors, with 66% having qualified outside the UK. The median number of LEDs employed per trust was 55, totalling over 18,000 doctors across responding trusts.
Doctors trapped for years in unsuitable roles
Despite Royal College of Physicians guidance recommending that doctors should transition from local contracts to nationally negotiated agreements after two years in the same specialty, The BMJ’s investigation uncovered alarming evidence of systemic non-compliance. Data from responding trusts showed that more than 4,000 LEDs – approximately one quarter of the total – had been employed by their trust for more than two years. Further analysis of nine trusts revealed that doctors from ethnic minority backgrounds were disproportionately likely to remain in LED roles beyond the recommended two-year period.
The investigation documented extreme cases of career stagnation. One surgeon with a South East Asian medical degree reported being on an LED contract for over 17 years. Despite her responsibilities expanding to include teaching, this work remained unrecognised in her contract, creating barriers to career advancement. When she raised concerns with management, she was told to either accept the situation or resign.
Another senior doctor in the East of England has spent nearly a decade attempting to secure the specialty doctor position she believes she qualified for in 2015. She estimates losing £25,000 annually compared to appropriate remuneration, stating: “There’s not many people like me who will stay 10 years in the job. I have family and health issues, so I can’t physically move to a new job – I’m just not in a position to.”
Systemic barriers to professional development
The investigation revealed that many LED contracts fail to provide structured supervision, educational support, or clear pathways for career progression. A doctor working in plastic surgery in the North West described his trust grade registrar contract as “a stagnant post – there is no scope for growth.” Despite having seven to eight years of experience, he lacks protected time for teaching and has no defined progression route.
A Yorkshire-based doctor from Pakistan, employed on a local contract for over two years, highlighted the absence of training opportunities: “Many of our trust grades have not had appraisals for the past two years. The trainees do get their appraisals. We don’t have teaching opportunities, and we don’t have time for learning. We can’t be stuck like this.”
Several international medical graduates described experiencing depression, burnout, and discrimination. One doctor reported working unsafe hours with minimal consultant oversight, irregular rotas, and overtime beyond safe limits in a permanently understaffed team.
Contracts lacking modern safeguards
Freedom of information responses revealed that many trusts employ contracts mirroring nationally agreed terms dating back to 2002, lacking protections introduced in the 2016 resident doctors’ terms and conditions. These older contracts omit mechanisms for exception reporting – the system allowing doctors to declare unsafe working hours and unplanned overtime.
Emma Runswick, deputy chair of council at the British Medical Association, characterised the findings as “further stark evidence of the way that locally employed doctors are exploited in a contractual ‘wild west,’ with dire terms and conditions and a lack of clear development opportunities.” She emphasised that “these doctors are disproportionately from ethnic minority backgrounds or are international medical graduates – contributing to the institutional racism within the health service.”
Calls for national framework and standardisation
Partha Kar, consultant endocrinologist and Royal College of Physicians elected councillor, advocates for a national framework holding trusts accountable. “It’s like having a parallel shadow industry within the NHS workforce,” he stated. “NHS England doesn’t have national guidance – at least some basics of what an LED contract should look like, which anybody can compare it to. That’s a big issue, and it opens up all sorts of issues around pay, working conditions, and training conditions.”
Rob Fleming, specialist anaesthetist and member of the SAS Collective campaign group, concluded: “We believe that locally employed doctors should be offered the appropriate permanent SAS contract for their work. As well as employment rights, this would give these folks the professional identity they are currently being denied.”
A Department of Health and Social Care spokesperson acknowledged that LEDs are “an integral and highly valued” part of the NHS, describing reports of inappropriate staff treatment as “completely unacceptable” and committing to improving working conditions through implementation of elements of the SAS pay deal.
Reference
Wilkinson, E., Boytchev, H., Rimmer, A. et. al. (2025). Revealed: Thousands of NHS doctors are trapped in insecure “gig economy” contracts. The BMJ, 391, r2383. https://doi.org/10.1136/bmj.r2383
