Thomas Grother’s decision to become a doctor was strongly influenced by visits to the Royal Glamorgan Hospital in Llantrisant when his grandfather was a patient there.

Dr Grother studied and now works within a small radius of his childhood home in the Glamorgan valleys. His first job as a foundation year 1 was in the Royal Glamorgan where, a decade on, nurses still remembered his grandad, Winston.

He is now a GP registrar, currently seconded to HEIW (Health Education and Improvement Wales) as a clinical leadership fellow, and co-chair of the BMA’s Welsh resident doctors committee.

So his commitment to medicine in Wales is deep-rooted and personal. But there’s no guarantee he will find a job in his home nation when he finishes training.

Last year's GMC workforce report found that ‘under a third (31%) of graduates from Welsh medical schools were still working in Wales five years later’.

For Dr Grother and WRDC co-chair Will Atkins, unemployment and underemployment sit high on the list of priorities they want the next Welsh government to address.

Competition ratios for training posts in some specialities are now 30 to one. They both know doctors with excellent portfolios who have failed to secure training jobs. The Welsh government recently froze the number of specialty training posts available, ignoring HEIW recommendations they should be increased.

A ‘multi-year, top-to-bottom review of workforce planning’ is long overdue, says Dr Atkins.

‘There is seemingly no long-term planning to ensure that we’ve got a sustainable pipeline of people going through the system who are being upskilled to meet the population’s health needs.’

The UK government’s decision in March to prioritise UK graduates for specialty training and the foundation programme is ‘helpful for UK graduates’, Dr Atkins says. But it is of no help to IMGs (international medical graduates), especially those who have already come to the UK and were ‘halfway through their applications’ when the government made its announcement.

Other opportunities for progression such as ‘safe, non-exploitative locally employed doctor contracts’ and pathways to specialist, associate specialist and specialty doctor contracts are an urgent priority.

‘But the fundamental problem is that there just aren’t enough jobs to go around.’

Too often, this means understaffing which leads to unsafe working conditions. Dr Atkins and his long-term partner at the time spent several years training in New Zealand where they ‘had time to care for patients properly’.

While he decided to return to the UK to be closer to family and friends, she decided to stay on because of the state of emergency medicine in the UK. ‘People are being forced to take those big decisions based on the way things are here,’ he says.

The new resident doctor contract that BMA Cymru Wales negotiated is more positive, with some progress on issues such as pay, working arrangements and study budget reform. But the push for full pay restoration to 2008 levels will continue.

‘We want to make sure the people of Wales are as fit and as well cared for as they can be, and to do that, you need doctors that are well looked after and enough doctors to do the job,’ says Dr Grother.

Adapting to life and work in Anglesey since she arrived in the UK in September 2024 has been a bumpy ride at times for psychiatrist Shivani Deshwal.

She has faced so many challenges that she has written an induction manual for IMGs like her who, she says, are not given enough guidance.

Role clarity as a senior clinical fellow was the first hurdle facing Dr Deshwal, who had previously worked as a consultant in India.

‘I didn’t know the system, when to say no, what is my job and what is not,’ she says. ‘I would say yes to everything. And I didn’t know that if I’m stuck, I can wait and ask [for support].’

It was colleagues who alerted her to the fact that she was being bullied, and they who encouraged her to report it.

Since then, she has felt well supported by her supervisor, colleagues and the Betsi Cadwaladr health board as a whole. She’s happy in her work with the community mental health team.

But Dr Deshwal, a member of the BMA Wales SAS doctors committee, is not happy with the mounting barriers to progression that she and other IMGs face.

She was disappointed not to be registered as a specialist doctor in the UK, given her previous experience – but accepted that she would need to build her portfolio in the UK.

Yet, it is only since coming to the UK that she has realised that the locally employed role of senior clinical fellow ‘does not necessarily offer a pathway to continuation or a permanent position’.

She is now pursuing specialist registration via the Portfolio Pathway (formerly CESR) but knows that her chosen route is ‘extremely challenging’.

Her health board supports her ambition to progress. ‘But in places like north Wales there can be limited opportunities to gather the required evidence [for a portfolio], and the clinical workload can make this even more difficult,’ she says.

‘How should I get involved in teaching, for example? How do I get the time for that?’

Friends’ experiences suggest that other health boards are far less supportive.

‘There are boards who actually say no to SAS doctors and are not providing any help [with progression]. They’re told: “You are only here for the clinical work.”’

More broadly, she understands UK graduate prioritisation for specialty training and the foundation programme. ‘It’s the government’s responsibility that if they have trained somebody here, they should be the priority,’ she says.

But, Dr Deshwal says, doctors who had already moved to this country and in so doing ‘made a very big sacrifice’, should not have been deprioritised for training – and should not be disadvantaged in terms of career progression, which she fears will increasingly be the case. ‘If you’re working equally hard, the opportunities should be equal.’

Generally, Dr Deshwal feels that IMGs, who account for more than a third of licensed doctors in Wales, deserve greater recognition and support from the next Welsh government. But she’s sanguine too.

‘If someone is getting on easier than you, there’s no point comparing. Your journey is your personal journey and you have to make it no matter how hard it is.’

For an outdoorsy, forward-looking, systems-thinking person like Sarah Osborn, Wales is a great place to study medicine.

The cycling, sea-swimming and mountain-climbing are the perfect antidote to work pressures and politics, and the potential for change in Wales is hugely motivating.

As a graduate-entry medical student at Swansea University, Sarah is currently living in rural Little Haven, working in general practice in Milford Haven, and grateful for privileges such as a car.

Through the university’s Primary Care Academy, she has the opportunity to work in an underserved part of Pembrokeshire and tot up lots of patient contact hours.

But she’s very aware that for many medical students and patients, Wales’ poor transport infrastructure poses significant hurdles. A 20-minute journey by car can take an hour or more by bus – when the buses are running.

Furthermore, an increasingly centralised health service means specialists are ever more widely dispersed.

‘I was previously on placement in Withybush Hospital [Haverfordwest] and they don’t have a paeds ward any more,’ she says, ‘so students who want to study paeds can’t do it there, and patients have to go all the way to Glangwili [Carmarthen] or Swansea.’

The primary care programme Sarah has joined is itself symptomatic of an overstretched system: it is designed to relieve pressure on doctors in training hospitals. ‘It’s a really lovely experience but it is a consequence of a health infrastructure that is unable to teach the future doctors it’s going to need,’ she says.

Uncertainty over foundation year allocations and specialty training places is a real concern among medical students, especially Welsh students who want to stay in Wales, says Sarah, who is deputy chair of the BMA Welsh medical students committee.

‘Powys doesn’t have a large hospital so if you’re from Mid Wales and want to help provide for the communities that you grew up with, you just don’t have the training opportunities you need to help those people,’ she says.

‘It also harms communities because they don’t have access to care, and we’re stuck in a system seeing health inequalities widen without the power to change it.’

Looking ahead to the next government in Wales, student finances are high on the agenda for the WMSC, including issues such as student loan forgiveness and improvements to the NHS Bursary. Sarah knows students juggling multiple jobs, others who have had to drop out for a year in order to work and raise funds.

Job uncertainty is equally stressful. Sarah, who is in year three of a four-year degree, already has a spreadsheet mapping out alternative career pathways, including options overseas.

‘There’s a feeling that as a recent graduate of medicine, your portfolio is not going to be strong enough so take F1, F2, F3, F4, F5, keep building it and then maybe the system will change.’

She is particularly concerned for students from overseas, even though they’re classed as UK graduates, as competition for jobs rises. ‘It’s really hard to see so much scapegoating because people perceive jobs are being taken by a visible “other”. It creates tension and makes the workforce harder to be in, which has knock-on effects for patient care too.’

For all these challenges, and perhaps because of them, Sarah is excited about the future of healthcare in Wales – or what it could be with the right investment and leadership.

‘Yes, you have patients with a lot of challenges, but there's also a really strong sense of community, a strong sense of national pride that can really motivate people to be the best version of themselves, so many people here who want to do good.

‘It's just that the infrastructure and organisational support is not there to enable it. But if all those changes were implemented, can you imagine doing all of the audits and the quality improvement programmes?

‘Wales could be an amazing place to work. It just has to have that vision enacted and enabled by politicians and the people who want it to work.’

• This is the third piece in our series on the Welsh NHS, prior to the election on Thursday. We've also covered primary care and other secondary care doctors