By Gemini

Audio summary: How NHS doctors work half the year

The shift toward flexibility is underpinned by the GMC’s determination that training should be assessed by evidenced capability rather than solely by time served. This philosophical change has profound implications for how rotational blocks are structured. Historically, medical training followed a “100% or nothing” paradigm, but contemporary standards allow for significant variations in intensity. The GMC’s position statement on LTFT training establishes that the clinical component of a post should not normally be less than 50% of full-time training. For a physician wishing to work only six months of a year, the 50% threshold represents the regulatory floor. While the Postgraduate Dean has the discretion to reduce this to a minimum of 20% in exceptional circumstances, such as severe ill health or complex caring responsibilities, these instances are typically time-limited to 12 months to prevent skill decay.   

The Gold Guide and subsequent deanery policies emphasize that LTFT training should offer the same opportunities as full-time training, differing only in the participation period. This principle of equivalence ensures that a physician working in a bipartite “6 on/6 off” block maintains their standing within the training program, provided they meet the curriculum requirements over a longer duration. However, the practical application of this flexibility is often contingent on “service delivery” and the capacity of the host Trust to accommodate non-standard rotas.   

Categorical Analysis of Less Than Full Time (LTFT) Pathways

LTFT training is categorized based on the physician’s reasons for seeking reduced hours. While the reasons vary, the ability to split a year into intense blocks of work followed by periods of absence is most common in Category 3 applications, though it is technically available across all tiers.

The expansion of Category 3, initially a pilot in high-intensity specialties such as Emergency Medicine, Paediatrics, and Obstetrics and Gynaecology, now allows any physician in a substantive NHS-approved training post to apply for flexible working without needing to prove “hard” necessity. This systemic shift acknowledges that the “shitness of the situation” in many acute departments can be mitigated by giving trainees agency over their schedules. For many, this agency manifests as the desire to work intensely for a block of time to facilitate prolonged periods of travel, rest, or non-clinical interests.   

The Annualized Hours Mechanism: Technical Implementation of Bipartite Rotas

For a physician wishing to remain continuously employed while working in a “6 months on and 6 months off” pattern, the annualized hours contract is the most robust mechanism. Instead of calculating working hours on a weekly basis, the total hours required for the year are calculated as a lump sum.   

Mathematical Framework of Annualization

To determine the commitment of an annualized LTFT physician, the employer converts weekly contracted hours into an annual total. A standard full-time week of 40 hours is the baseline.

The conversion formula is as follows:

Hannual​=Hweekly​×52.143

Where Hannual​ is the total annual paid hours.   

For a physician working at 50% LTFT (which equates to six months of full-time work spread over a year), the calculation involves deducting pro-rata annual leave and bank holiday entitlements from the total to find the “working hours” target.   

In a “6 months on/6 months off” scenario, the physician would complete their total 911.55 working hours during the first half of the year (by working a 40-hour week for six months) and then take the subsequent six months off. A critical benefit of this model is “salary smoothing.” The Trust pays the salary in 12 equal monthly installments, regardless of whether the physician is in their “on” or “off” block. This provides financial security during expeditions or extended periods of rest.   

Operational Realities and Self-Rostering

The success of annualized bipartite rotas is often dependent on “self-rostering,” where the physician books their shifts rather than booking their time off. In Emergency Medicine, this allows for a mature approach where the physician can front-load their clinical commitment to free up blocks of time later in the year. This is particularly advantageous for those pursuing a “portfolio career” or “expedition medicine,” where short-notice missions require sudden blocks of time off. However, this model requires a sophisticated e-rostering system, such as SMART or Allocate, to track the “time-stamped” requests and ensure that the total PAs (Programmed Activities) are met.   

Out of Programme (OOP) Modalities for Extended Absence

When a physician requires a total separation from their training post for six months without the requirement to complete the “on” block within the same year, the Out of Programme (OOP) suite of options is utilized. These are formally governed by the Gold Guide and require approval from the Postgraduate Dean.   

Out of Programme Pause (OOPP) and Career Breaks (OOPC)

The OOPP is a strategic retention tool that allows trainees to step out of their National Training Number (NTN) to work in a clinical capacity outside of their formal training program.   

• Duration and Discretion: A one-year pause is often granted “no questions asked,” with a second year possible at the Dean’s discretion.   
• The “6/6” Utilization: A physician can use a one-year OOPP to work for six months in a high-paying locum or trust-grade role and then take the next six months off entirely for personal pursuits.   
• Return Rights: After a maximum of two years, the physician must return to their training post or face the resignation of their NTN.   

OOPC (Career Break) differs from OOPP in that it is explicitly for non-clinical reasons, such as domestic responsibilities, travel, or career diversification. While OOPC allows for a six-month block off, it does not typically permit locum work, as it is intended for a total cessation of medical activity.   

Out of Programme Experience (OOPE) and Research (OOPR)

OOPE is designed for gaining professional skills that, while not curriculum-mandated, enhance a physician’s future consultant practice. This is frequently used for humanitarian missions with organizations like Médecins Sans Frontières (MSF) or for Global Health Volunteer Fellowships. In these cases, the “6 months off” is actually six months of working in a different, often challenging, health environment.   

Integrated Clinical Fellowships: The “Bristol-MSF” Model

One of the most concrete examples of a structured “6 months on and 6 months off” (in terms of UK training) is the hybrid clinical fellowship model. These posts are designed for middle-grade doctors (ST3+) and provide a formal bipartite split between NHS work and international field work.   

Case Study: Paediatric/MSF Hybrid Fellowship

This role, often based in units such as the University Hospitals Bristol NHS Foundation Trust, advertises a 12-month contract split into two distinct six-month phases.   

1. The NHS Block (6 Months): The candidate works on a standard middle-grade rota in a UK paediatric department, receiving supervision and participating in departmental projects.   
2. The MSF Block (6 Months): The candidate is deployed as a paediatrician in an MSF field project. While this is technically separate employment, it is administratively linked to the UK post to provide continuity of service.   
3. Prerequisites and Support: Candidates must have completed ST3 training and often need B1-level French capability. Supervision is maintained remotely by MSF France paediatric advisors, ensuring that the clinical skills gained abroad are integrated back into the candidate’s professional development.   

Global Health Volunteer Fellowships (GHVF)

Similarly, the GHVF program enables doctors in training to volunteer for 4 to 6 months in supervised clinics in Africa. These placements are “well-vetted” and focus on leadership, decision-making, and resilience. While these fellowships are often unpaid by the NHS, they allow a physician to step out of the “grind” of the UK system for a six-month block, essentially trading their NHS salary for international experience.   

Step On Step Off Training (SST) for General Practice

General Practice (GP) training has developed its own bespoke flexibility framework known as Step On Step Off Training (SST), which recognizes that GP trainees can gain significant competencies from diverse working practices.   

SST allows for two primary types of “stepping off”:

• Deferred Start (Option 1): Successful applicants can defer their GP training for up to 12 months for any reason, facilitating an early “gap” before the ST1 year begins.   
• Time Out During Programme (Option 2): Trainees can take time out between ST1 and ST2, or partway through ST1, to pursue clinical fellowships or academic opportunities.   

The SST policy is explicitly designed to support “self-construct” posts, where a trainee might organize their own six-month stint in an overseas hospital or a UK-based leadership role. This modularity is a critical feature of the “GP Plus” training model, which seeks to make General Practice more attractive by allowing for these “on/off” training blocks.   

Financial and Administrative Constraints: The Barrier of the Skilled Worker Visa

While the policy landscape is increasingly supportive of flexibility, the practical execution of a “6 months on/6 months off” pattern is heavily constrained by the legal requirements of the UK visa system. For International Medical Graduates (IMGs) on a Skilled Worker (formerly Tier 2) visa, the Home Office mandates minimum salary thresholds and continuous employment conditions.   

Salary Thresholds and LTFT Limitations

A physician working at 50% LTFT (effectively taking half the year off) must still ensure their total annual salary meets the Home Office requirements. As of 2024, these thresholds are significant relative to junior doctor salaries.   

For an FY1 or FY2 doctor, it is virtually impossible to train at 50% (and thus take six months off) while on a Skilled Worker visa, as their pro-rata salary would fall below the Home Office minimum. Only at the ST3+ level does a 50% salary comfortably exceed the threshold, allowing for the “6 on/6 off” model. Furthermore, any period of “six months off” that involves zero pay must be carefully managed; if the Home Office perceives a cessation of employment, the visa may be curtailed.   

Pension and Indemnity Considerations

Working in a bipartite block pattern also has implications for the NHS Pension Scheme. Contributions are only made on the pensionable pay received during the “on” block. If the physician is on an unpaid OOPC for six months, they miss out on half a year of service and employer contributions. Similarly, professional indemnity through organizations like the MDU or MPS must be adjusted; while many providers allow for reduced subscriptions for LTFT work, they must be informed if a physician is taking a total clinical hiatus for six months to ensure coverage remains valid upon their return.   

Educational Integrity: Assessment, ARCP, and Skill Retention

The General Medical Council’s primary concern with flexible training is the maintenance of clinical safety and the progression of capabilities. A physician absent for six months is at risk of “skill retention only,” rather than progression, particularly in procedural specialties like Obstetrics and Gynaecology or Anaesthesia.   

The ARCP Process in Bipartite Training

The Annual Review of Competency Progression (ARCP) remains a mandatory annual requirement regardless of the training pattern. For a “6 on/6 off” trainee:   

• Pro-rata Evidence: The trainee must provide evidence of progress proportional to their time in training. If they have worked six months of a 12-month window, they must have completed 50% of the required Workplace Based Assessments (WPBAs).   
• The Multi-Source Feedback (MSF): Peer assessment (360-degree feedback) is mandatory. In a bipartite rotation, the MSF should be undertaken in the 5th month of the “on” block to ensure a sufficient number of colleagues can provide feedback.   
• CCT Extension: Every month taken “off” results in a one-month extension to the final CCT date. A physician consistently working 6 months per year will take exactly twice as long to qualify as a consultant.   

Supported Return to Training (SuppoRTT)

Given the potential for skill decay during a six-month hiatus, the “Supported Return to Training” (SuppoRTT) program is a critical component of the “6 off” model. This program provides a structured period of supervised work, simulation training, and an “initial return to work” meeting with the Educational Supervisor to ensure the physician is safely reintegrated into the clinical environment.   

Regional Variation and Local Policy Nuances

The implementation of “6 months on and 6 months off” is not uniform across the United Kingdom. Deaneries in Scotland, Wales, and England have local variations that affect the feasibility of such rotas.

Scotland: The 4-Month Block Constraint

In the Scottish Foundation School, LTFT is supported but governed by the “4-month block” principle. Because foundation rotations in Scotland are strictly set as three 4-month placements, any bipartite split must align with these blocks. It is often only possible to take a block off when returning from maternity or parental leave partway through a year, and the deanery emphasizes that “geographical proximity cannot be guaranteed” when trying to accommodate such complex LTFT requests.   

North West and East Midlands: The 16-Week Notice Rule

In deaneries like NHS England North West and East Midlands, any change in training intensity (e.g., shifting from 100% work to the “off” block) requires a minimum of 16 weeks’ notice. This notice period is essential for rotation planning, as the Training Programme Director (TPD) must find another trainee or a locum to fill the “gap” created by the six-month absence.   

The Role of SAS Doctors and Clinical Fellows in Bipartite Working

Physicians who choose to step out of formal training programs often find the “6 months on and 6 months off” pattern easier to achieve as Specialty, Associate Specialist, and Specialty (SAS) doctors or Trust Grade Clinical Fellows.   

• SAS Flexibility: SAS doctors work on a contract defined by Programmed Activities (PAs). A full-time contract is 10 PAs, but SAS doctors have the statutory right to request flexible working without the “competency progression” pressures of a training program.   
• Trust Grade Roles: Many Trusts hire doctors directly into 6-12 month contracts to fill service gaps. A “6 months on/6 months off” lifestyle can be achieved by working one of these fixed-term contracts and then resigning to travel or rest, before applying for a new post six months later.   
• Locum Tenens: The “Larry Locum” route remains the most flexible, albeit the most insecure, path to bipartite working. A doctor can work intensely as a locum for six months, save a significant “war chest,” and then take six months off with no administrative overhead other than maintaining their appraisal and revalidation status.   

Impact on Service Delivery and the Crisis in Emergency Medicine

The Royal College of Emergency Medicine (RCEM) has been a vocal advocate for flexibility, noting that appalling working conditions and “burn-out a reality” have driven many to leave the specialty. The RCEM’s “EM-POWER” guide argues that flexible rotas, including annualized hours and block working, are essential for workforce sustainability.   

However, there is a recognized “Risk of Net Reduction” in the workforce if large numbers of trainees move to 50% working (the “6 on/6 off” equivalent) without a corresponding increase in recruitment. For every trainee taking six months off, the system loses half of a full-time equivalent, which, if unfilled, increases the burden on the remaining staff. This has led some deaneries to restrict Category 3 LTFT applications to a certain percentage of the workforce (e.g., 10-15% of a specialty) to maintain service safety.   

Conclusions and Practical Guidance for Physicians

The “6 months on and 6 months off” training pattern is a viable, albeit complex, professional arrangement in the UK. For physicians in a National Training Number (NTN), the most sustainable route is the Annualized Hours LTFT model under Category 3 eligibility, as it maintains employment benefits and provides salary smoothing. For those seeking international experience or a total break, the Out of Programme Pause (OOPP) or Hybrid Clinical Fellowships (such as the Bristol-MSF post) offer structured bipartite splits.   

Physicians seeking this level of flexibility must adhere to the following procedural steps:

1. Early Engagement: Discuss plans with the Educational Supervisor and TPD at least 12–18 months in advance, as rotation planning occurs far ahead of start dates.   
2. Eligibility Verification: Ensure that your training grade and salary meet the minimum requirements for your visa status, particularly for IMGs.   
3. Formal Application: Submit a LTFT or OOP application through the relevant deanery portal (e.g., the Trainee Self Service portal) with at least 16 weeks’ notice.   
4. Work Schedule Negotiation: Liaise with the host Trust’s “Champion of Flexible Training” and the e-rostering team to set up an annualized pattern on systems like SMART/Allocate.   

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