Policy responses and statements

Name of organisation:

UK Parliament:Health Committee

Name of policy document:

Inquiry - Modernising Medical Careers

Deadline for response:

16 October 2007

Background: The Health Committee will hold an inquiry into the Modernising Medical Careers programme (MMC) and its implementation through the Medical Training Application Service (MTAS). The inquiry will take account of the interim findings of the ongoing inquiry, led by Professor Sir John Tooke.

The Committee's inquiry will focus particularly on:

What are the principles underlying MMC and are they sound;

To what extent the practical implementation of MMC has been consistent with the programme's underlying principles;

The strengths and weaknesses of the MTAS process;

What lessons about project management should the Department of Health learn from the failings in the implementation of MMC;

The extent to which MMC has taken account of the supply and demand of junior doctors and the number of international medical graduates eligible for training in the UK;

The degree to which current plans for MMC will help to increase the flexibility of the medical workforce; and

The roles of the Department of Health, Strategic Health Authorities, the Deaneries, the Royal Colleges and the Postgraduate Medical Education and Training Board in designing and implementing MMC.

Organisations and individuals are invited to submit written evidence. Written evidence should if possible be in Word or rich text format-not PDF format-and sent by e-mail to healthcommem@parliament.uk . The body of the e-mail must include a contact name, telephone number and postal address. The e-mail should also make clear if the submission is from an individual or on behalf of an organisation.

Submissions must address the terms of reference. They should be in the format of a self-contained memorandum and should be no more than 3,000 words. Paragraphs should be numbered for ease of reference, and the document must include an executive summary. Further guidance on the submission of evidence can be found at ww.parliament.uk/documents/upload/witnessguide.pdf .

Submissions should be original work, not previously published or circulated elsewhere, though previously published work can be referred to in a submission and submitted as supplementary material. Once submitted, your submission becomes the property of the Committee and no public use should be made of it unless you have first obtained permission from the Clerk of the Committee.

COMMENTS ON
UK PARLIAMENT: HEALTH COMMITTEE
NEW INQUIRY - MODERNISING MEDICAL CAREERS

The Royal College of Physicians of Edinburgh is pleased to respond to the Health Committee’s Inquiry on Modernising Medical Careers.

EXECUTIVE SUMMARY

The Royal College of Physicians of Edinburgh is committed to developing a more responsive training system in the UK and several senior officers and many Fellows and Members have been involved in the design and implementation of the MMC and MTAS systems.  However, the College cannot emphasise too strongly the disillusionment and distress caused by the failures of the system this year and the effort that will be required to regain the confidence of the profession.

The College is keen that the potential benefits of MMC are not lost in the rush to address the very serious deficiencies of MTAS, and agrees that any changes following the recommendations of Professor Sir John Tooke should not take effect until 2009.  That said, it is imperative that doctors applying for foundation and specialty training in 2007 and 2008 are treated fairly and clear transition arrangements must be agreed quickly.

The main points of the College’s evidence are as follows:

• The intended flexibility in MMC was more theoretical than real.  Early selection and run through training limited future options.
• Medical workforce planning must improve and be aligned to training schemes.  The position of international medical graduates must be clarified.
• Fixed Term Specialty Training Appointments must be used in the short term only.
• There should be a single medical regulator covering all aspects of medical training and registration.
• Selection procedures must take due account of academic and clinical performance, supported by structured CVs.
• Applications to a national system for 2009 must be managed through a computerised system and processed locally through deaneries.  Any new system must be rigorously piloted and tested to avoid the practical problems of this summer and regain the confidence of applicants.
• Effective risk assessment and contingency planning must be applied to all future training projects and must operate within a sensible time frame.
• The departments of health in the 4 administrations must be committed to full consultation with relevant stakeholders throughout the design, piloting and implementation phases of any future changes.
• The role of NHS consultants in this important task must be recognised in consultant job plans

INTRODUCTION

1. The Royal College of Physicians of Edinburgh (RCPE) has a long and tested history in the development of medical training in the UK, latterly through its partnership with other Colleges in the Federation of Royal Colleges of Physicians of the UK and the Academy of Medical Royal Colleges and Faculties.  We have been campaigning since the mid-1990s for improvements in the training programmes for Senior House Officers (SHOs) and had identified many of the issues raised in Professor Sir Liam Donaldson’s ‘Unfinished Business’1, 2.  Many of the initial proposals within MMC were therefore welcomed as long overdue but with major caveats, primarily the need for more flexibility and the importance of maintaining standards.

2. However, professional confidence in the new training systems at all levels has been shattered by the disastrous implementation of the Medical Training Application Service (MTAS).  These acronyms are used interchangeably which is both incorrect and extremely damaging as the undoubted problems of MTAS infect and undermine the positive aims of MMC.  Changes to the systems are required urgently but there is an equally urgent “hearts and minds” challenge and a need to address the problems of those trainees who have been let down badly by the system this year.

3. Professor Sir John Tooke’s report has captured many of the key strategic and operational difficulties and, in principle, the College welcomes most of his proposals.  Flexibility and fairness must be enshrined in any changes to current systems and arrangements confirmed quickly for those doctors appointed to Foundation or ST posts in 2007 and 2008.  The College will be providing a detailed response after further discussion with Fellows and Members.

The Principles underlying MMC

Flexibility

4. Revisiting the College’s response to ‘Unfinished Business’ serves to emphasise the original and welcomed intention to establish a much more consistent yet flexible system of training, encouraging trainees into the less popular specialties, and addressing the unsatisfactory position of staff grade and associate specialist doctors.  Such flexibility is essential to facilitate career change, progress at a pace consistent with acquisition of competences and be responsive to the changing needs of the NHS.

Moving towards a Trained Workforce

5. Trainees and many trainers have expressed concern that an unstated driver of MMC was to reduce training periods and create a new grade of sub-consultant specialist to meet the financial needs of the NHS.  Young graduate doctors are among the brightest of their generation and the market for medical staff is global.  They will seek better opportunities abroad if consultant jobs in the UK are limited. 

6. Many of those within the system this year expressed the view that MTAS was designed to fill NHS junior posts rather than select those best suited into particular specialist training programmes.  This perceived conflict between service and training focus need not occur if the training benefits of service delivery and recruitment methods are improved and better understood.

Quality Assurance

7. MMC was not to be accomplished at the expense of competence and the Colleges have introduced curricula-driven foundation and basic and specialist training programmes, supported by robust assessment systems.  Significant investment is required in training resources, in the infrastructure to support the new training programmes, and in quality assurance.  Perhaps the most underestimated investment has been in the time required of consultants in the training, supervision and assessment of trainees and how this will be managed against the background of new job plans and consultant contracts.

8. The track record of the Colleges generally in the supervision and assessment of individual trainees and the quality assurance of programmes has been questioned, although little of this has been supported with clear evidence.  The Postgraduate Medical Training and Education Board (PMETB), established in response to ‘Unfinished Business’ to replace the “regulatory” role of Colleges in specialist postgraduate medical education, has been slow to start and appears expensive.  It has failed to win the support of the profession, and we believe a fundamental review of its role is required urgently.  In particular, the College calls for a cost-benefit review of retaining 2 medical regulators (GMC and PMETB) and would prefer to see regulation integrated into a single organisation supporting safe and effective practise from medical school to retirement.  The GMC seems ideally placed to assume this cradle to grave role, and we note the Tooke recommendations in this regard.

Practical Implementation of MMC

Foundation Programme

9. The Foundation Programme, as the first component of MMC to be established, has had a mixed reception with our trainees.  Those who are undecided about their future career are more positive towards a 2 year general programme with increased opportunities to try different specialties.  Trainees with firm career aspirations can be less impressed, particularly if their attachments take them away from their preferred areas and they are discouraged from specialty work or study.  Trainers report that this is evident from their attitude and performance, and deaneries must be innovative in their programme development to engage the attention of these ambitious young doctors.  The College recognises that Tooke has recommended further changes in the structure of the Foundation programme. 

Transfer of competences/shared training

10. The generic core of general medicine, felt to be essential to all medical specialties, was retained after a forceful defence by the 3 Colleges of Physicians of a 2 year Core Medical Training (CMT) programme.  The development of an updated curriculum for this programme will improve the consistency of training.  The College welcomes the implication in the Tooke Report that a longer period of general training in medicine will be reinstated for a wider range of trainees, before further specialisation.  This will facilitate choice and selection into the specialities, allowing trainees to experience more options before determining their career choice and to demonstrate aptitudes.  The College is well placed through its internationally recognised MRCP(UK) qualification to assess the relative performance of trainees and support selection into specialty.

Run Through Training (RTT)

11. What has become known as Run Through Training (RTT) has resulted in a rigid career path for doctors with early selection and very limited opportunities for change.  Whilst helpful for delivering predictable numbers of trained doctors within set programmes, RTT has significant disadvantages, namely:

• A highly pressurised selection environment where candidates compete for what they perceive to be their only chance to enter the speciality of choice and with only 4 choices.  This was particularly marked for trainees already in medical SHO posts and therefore committed to medicine.
• Early selection, forcing premature choice for many doctors and often before they have had the opportunity to demonstrate competence or aptitude and limiting options to change thereafter.
• Less opportunity to experience work in the less popular specialities to encourage recruitment

12. Allocation into specialty after CMT reintroduces the concept of competition and has led in this introductory year to major concerns about the detail of the “promise” in RTT.  Trainees have been reassured that they will be guaranteed a specialist training place but not necessarily in their preferred speciality.  In Scotland, it is clear that many specialities will have few or no training opportunities each year and career progression could become a real lottery unless some geographical flexibility is permitted.  Equally, other trainees may prefer a deanery-specific training programme for domestic stability. A hybrid approach may be feasible, and some certainty is required urgently for 2008.

Strengths and Weaknesses of the MTAS Process

13. MTAS attracted such criticism with emotions running high, and it is all too easy to overlook what worked within the system.  The previous system of open and uncoordinated competition across the UK for each post was neither fair nor efficient and had to change.  There are some glimmers of hope for a better system in certain aspects of MTAS but it would be exaggerating to call them strengths at this stage.  These include:

• The application system appeared to work better for GPs than consultants.
• Trainees could see all job opportunities simultaneously.
• An on-line system has the potential to make the screening of applications more manageable for consultants.
• The application system was well promoted, attracting interest from large number of UK and international trainees.

14. But MTAS had many serious problems, some of which can be attributed to the design of the system and others to implementation at a local level.  None must be repeated in 2008.  The main areas of concern include:

14.1 Deficient short listing systems

• The forms for short-listing failed to discriminate reliably between candidates.  This College and others had been involved at the early design stage, but the MMC team responsible for delivery were driven to such tight timelines that full consultation with the clinical experts within the Colleges was not achieved and fundamental deficiencies remained unchallenged.  Person specifications were insufficiently discriminating, perhaps driven by concerns about equity and diversity.  In the future, standardised application documentation must be complemented by structured CVs.
• The application forms were not available to consultants in advance of MTAS going live to allow them to get to grips with the new system and support trainees applying for the first time.
• Some deaneries had local implementation difficulties, resulting in hurried assessments, compromised quality and disillusioned assessors.  There were also anecdotal reports of non-clinical input into short listing.

14.2 Deficient interview information

• Structured CVs and portfolios at interviewing are essential to allow assessment on merit.  Information on clinical and academic achievements is essential to discriminate between candidates.
• There is now clear evidence to support the long accepted differences in the ability and knowledge of graduates from different medical schools and a growing need to calibrate medical degrees or test knowledge and competence during the Foundation Programme to support the selection process.
• Interview processes were inconsistent between and within deaneries, leaving applicants dissatisfied and employers vulnerable to appeal.
• The restriction on applications to 4 posts per trainee would inevitably result in some excellent candidates failing in their first choices and entering round 2.  Interview panels were advised strongly by the review team to restrict offers to excellent candidates in round 1, as there would be other high quality candidates in round 2.  The timing delay and pressures to fill posts no doubt discouraged panels from this approach and, as a result, some excellent candidates were at high risk of unemployment.
• The GPs’ experience of incorporating structured assessment stations to assess knowledge and aptitude was helpful and could be usefully applied to other specialties.

14.3 Unreliable computer system

• There were many examples of defective functions which eroded the confidence of trainees and trainers.  In addition to the well publicised security breaches, this College has anecdotal reports of trainees losing data from their applications, being unable to input data in some sections and many expressed the fear of the system crashing denying them the opportunity to complete applications within very tight deadlines.
• The promised plagiarism detection components failed. 
• The system was developed quickly and went live with inadequate piloting.  It was a new IT system, supporting a very new application process, for all UK trainees simultaneously.  There was no obvious risk assessment or recovery plan for when the system failed.

14.4 Ineffective communications strategy

• The web-based communication and e-mail alerts may have worked effectively if the application process and IT system had not also experienced serious problems. Emotions were running high, media reports were inflammatory and deaneries were giving different messages to their applicants.  The result was confusion and significant stress for trainees and anger among consultants who felt powerless to support their distressed junior colleagues. 
• The lack of accurate and timely information about application and competition ratios made it difficult for corrective action to be agreed and implemented and for candidates to review their choices.  It is essential that careers advice, including information about future job prospects is available to trainees and their trainers to encourage realistic applications.  This should be a high priority for all deaneries next year, who will require support from national workforce planning teams.

14.5 Scale and timing

• It seems incredible that a new training system with untested IT support would be introduced simultaneously across all specialties and deaneries in the UK. Compressing all trainee recruitment in this way is unwise, and a staggered approach would both allow trainees other opportunities to apply and the NHS to accommodate the loss of doctor time.  
• The 4 nations took a different approach to implementation of corrective action, causing some disquiet among trainees eg for logistical reasons, candidates in England were guaranteed their first choice interview only, whereas the devolved administrations offered interviews for all 4 preferences.
• Better coordination of the timing of job offers is essential to avoid a race to grab the best candidates.
• The delay in appointing posts caused disruption for some clinical teams.  In addition to the usual changeover pressure experienced in August each year, gaps appeared as appointed trainees deferred their start dates or employers struggled to achieve pre employment checks.

Project Management Learning Points

15. A common theme to all the listed learning points is more timeto: