The first phase of NHS England's assessment of medical training is the most comprehensive assessment of postgraduate medical training in more than a decade, based on more than 8,000 responses. The assessment revealed that, despite major changes in healthcare demand, educational structures have changed little over the past two decades. Systemic problems were identified, including increasing competition for training posts, a mismatch between service provision and education and inflexible learning pathways. Serious barriers limit progression in education, particularly after foundation training, with over 77% of doctors completing Foundation Year 2 in England not progressing or being able to progress directly to foundation training in 2023. As competition intensifies, many physicians move into non-teaching positions, fueling the growth of locally employed physicians. These jobs often offer inconsistent access to supervision, professional development, and career advancement, creating inequity among major conflicts.