Many challenges remain in improving training provision in our field. How can they be addressed, and what opportunities should we investigate?

The introduction of the revised 2022 General Medical Council-approved curriculum represented a significant step forward for endocrinology and diabetes training, embedding capabilities in practice (CiPs), dual accreditation with internal medicine, and a more holistic approach to assessment. 

However, for many trainees and educational supervisors, the reality of training has not fully reflected the aspirations of curriculum reform. Increasing service pressures, escalating clinical demand and a finite workforce capacity have combined with rising curricular expectations to create tension between service provision and high-quality training. While perspectives differ, there is broad consensus that current training structures do not consistently allow trainees to receive, or trainers to deliver, training in the way originally envisaged. 

Persistent challenges remain, including workforce uncertainty, service pressures and variability in training opportunities across the UK. Addressing these requires a shared understanding of constraints, alongside joint ownership of pragmatic solutions that support high-quality training for a skilled future workforce, while maintaining safe and sustainable services.

WORKFORCE PRESSURES AND CAREER UNCERTAINTY

One of the most pressing concerns for our trainees is the increasing mismatch between the growing clinical burden of diabetes and endocrine disease and the availability of substantive specialty consultant posts. Despite rising demand, consultant expansion has not kept pace with trainee output. As a result, some doctors face a period of post-Certificate of Completion of Training (CCT) uncertainty, taking up locum, non-substantive roles or seeking opportunities abroad. 

 

This bottleneck risks undermining morale and recruitment at a time when the specialty can least afford it. Better national workforce planning is required, aligned with population need and evolving models of care. Expansion of hybrid consultant roles, for example combining diabetes with obesity medicine, peri-operative care or community diabetes services, would better reflect modern practice and create more flexible career pathways.

 

SERVICE PROVISION VERSUS SPECIALTY TRAINING

Diabetes and endocrinology is predominantly an outpatient specialty, with much of the most valuable learning occurring in clinics, multidisciplinary team (MDT) meetings and longitudinal patient follow-up. 

However, trainees consistently report that general internal medicine (GIM) service commitments frequently encroach on specialty training time. While GIM remains a vital component of training, excessive service pressure risks diluting specialty experience, particularly in later years, when advanced competencies should be consolidated. 

Protecting specialty clinics and MDT exposure is therefore essential. Nationally agreed minimum clinic benchmarks aligned with curricular CiPs could help ensure that training outcomes are achievable across all regions.

VARIABILITY AND INEQUITY IN TRAINING EXPERIENCE

Variation in training experience across deaneries remains another significant challenge. Access to specialist clinics such as diabetes technology, pregnancy, transition, obesity or rare endocrine services often depends on geography rather than training need. Teaching provision, and access to simulation-based training and research opportunities, also vary widely, creating inequity in preparation for consultancy. 

Less-than-full-time trainees can be particularly affected, therefore expanding high-quality hybrid and recorded teaching alongside invaluable in-person sessions can help reduce regional variation and improve accessibility. Consideration should also be given to cross-deanery educational opportunities.

RECRUITMENT AND EARLY EXPOSURE

 

Despite its breadth and relevance, diabetes and endocrinology remains underrepresented in undergraduate and early postgraduate training. Many doctors have limited exposure beyond inpatient diabetes care, which can perpetuate misconceptions about the specialty being service-heavy or lacking career progression. 

 

Guaranteed exposure during foundation and internal medicine training, national taster programmes and structured mentorship would help attract high-quality applicants. Showcasing portfolio careers, leadership opportunities and work–life balance may also help challenge outdated perceptions of the specialty.

THE WIDER MULTIDISCIPLINARY CONTEXT

Training quality does not exist in isolation. Shortages within the wider MDT, particularly specialist nurses, place additional pressure on services and reduce opportunities for shared learning. Investment in MDT staffing should be viewed as a parallel investment in training quality and future workforce sustainability.

OPPORTUNITIES FOR MODERNISATION AND INNOVATION

There is considerable opportunity to future-proof diabetes and endocrinology training. Formal recognition of subspecialty interests within training such as diabetes technology, obesity medicine, reproductive endocrinology and endocrine oncology would better reflect current and future service needs. 

Greater curricular emphasis on digital health, remote monitoring, population health and service redesign would equip trainees with skills increasingly required in consultant practice. Funded post-CCT fellowships or credentialing pathways could support this development, while enhancing workforce flexibility.

SUPPORTING WELL-BEING AND FLEXIBLE CAREERS

Trainee well-being and retention must be central to any training reform. Normalising less-than-full-time training, ensuring transparent rota design and guaranteeing equitable access to clinics, courses and research time are essential steps. Strong trainee representation through forums such as the Young Diabetologists and Endocrinologists’ Forum plays a vital role in ensuring that training evolves in response to real-world experience.

SHARED CHALLENGES FOR THE TRAINEE AND TRAINER

Many of the pressures facing trainees and trainers are shared. Trainees cite reduced access to specialty clinics, high GIM workloads and uncertainty about post-CCT employment. Trainers highlight increasing clinical demand, rota gaps and limited job-planned time for education.

These are not competing priorities but interconnected challenges. When service pressures intensify, training quality suffers, undermining future workforce capacity and morale. Meaningful solutions must operate at organisational and national levels, rather than relying solely on local adaptation.

LOOKING FORWARD

UK diabetes and endocrinology training stands at a pivotal moment. Curriculum reform has laid strong foundations, but further structural change is required to ensure training is equitable, sustainable and aligned with modern clinical practice. Improving workforce planning, protecting specialty training time, reducing regional variation and embracing flexible, future-focused career pathways would not only enhance trainee experiences, but also strengthen the specialty as a whole. 

As the burden of diabetes and endocrine disease continues to grow, investing in high-quality training is essential to securing the future of patient care.

NEERA AGARWAL
Chair of the Specialist Advisory Committee UK (Diabetes and Endocrinology), and Clinical Director for Diabetes, Cardiff and Vale University Health Board