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Health Select Committee Inquiry into Modernising Medical Careers and its implementation through the Medical Training Application System

Response from the British Medical Association
October 2007

The British Medical Association is an independent trade union and voluntary professional association which represents doctors from all branches of medicine all over the UK. It has a total membership of over 139,000.

Executive summary

• The BMA responded to the Tooke Inquiry on MMC and encloses its response with this evidence. The BMA also sits on the MMC Programme Board and communicates the views of doctors through four elected representatives that are members of the profession.
• The BMA has been appalled at the rushed implementation of Modernising Medical Careers in 2007 and called for a delay in implementation in 2006. However, the original principles behind the reform in specialty training are supported by the BMA. It is important to highlight that what was originally envisaged has not materialised and it is now necessary to assess, define and establish the training pathways of the future.
• The haste with which MMC was introduced severely hampered any opportunity to introduce any of the principles behind the reform. It is clear that despite the warnings from the BMA, the Department of Health moved forward with a programme that did not have the full confidence of the profession or other stakeholders. It is also important to note that implementation in the devolved nations was not as problematic; the reason for this has been attributed to strong professional engagement and the realisation that this should have been a transitional period. However, it was unfortunate that some decision makers in England ignored the impact that some of their policies would have on the devolved nations.
• The BMA is gravely concerned that the principle of flexibility has been eradicated from plans for the future of training and would like to see a greater emphasis placed on pathways for re-entry to training, whether it be from research, fixed term specialty training appointments (FTSTAs) or the staff and associate specialist grade, as well as more focus on flexible training opportunities for trainees.
• A national recruitment process can have its rewards; mainly it helps the applicant access more opportunities with lower levels of administration and reduces any local bias. The hurried implementation this year has highlighted the problems of an online system and has seen the profession lose faith in a computer system that failed to deliver a fair selection process. The recent consultation by the MMC Programme Board recognised that a computer portal could not be implemented for 2008 but is a possibility for 2009 subject to stringent piloting.
• The inclusion of the new Academic Clinical Fellowship posts in the MTAS system was a mistake that contributed significantly to the low fill rate of 57% and has further compounded recruitment to academic medicine. Academic posts should be disaggregated from clinical training posts, and recruitment should preferably take place before clinical training. Proper information should be made available to all trainees about an academic career.
• In future, as clearly pointed out by the Tooke Inquiry, the Department of Health must actively engage with the profession and heed constructive comments and advice rather than seeing them as a challenge to their authority, whilst effectively communicating decisions to those they affect.
• It is evident that ineffective workforce planning has hindered the implementation of MMC, and this was a principal finding of the Tooke Inquiry. The BMA continues to highlight the needs for effective workforce planning, where workforce patterns are based on need and not artificially restricted on the grounds of affordability. It is also essential to take into account current and planned medical school intake, coupled with future migration and immigration.
• The recent report by the Tooke Inquiry is an academic critique of the Government’s failings this year. It has made many recommendations, all of which should be considered in the short and medium term, allowing us to reassess the future of the profession as a package. In order to do this, the BMA intends to conduct a survey and hold a conference on the recommendations which will assess the views of the profession on the future of medical training.

What are the principles underlying MMC and are they sound?
1. The original principles of MMC were first cited in ‘Unfinished Business: Proposals for Reform of the Senior House Officer Grade, 2002’, a report by the Chief Medical Officer, Sir Liam Donaldson. These were that :

• training should be programme-based;
• training should begin with broadly-based programmes pursued by all trainees;
• programmes should be time-limited;
• training should allow for individually tailored or personal programmes;
• arrangements should facilitate movement into and out of training and between training programmes.

The BMA supports these original principles and has been dismayed that the current implementation deviated so widely from these.

2. In addition, the ‘seven pillars’ of MMC were first written in ‘Modernising Medical Careers – the next steps, 16 April 2004’. These stated that training should be:

• trainee centred
• competency assessed
• service based
• quality assured
• flexible
• coached
• structured and streamlined.

Whilst the principles outlined above continue to have strong support from the BMA, there is a need to reinforce, review and better define them and to ensure that more than lip service is paid to observing them.

To what extent has the practical implementation of MMC been consistent with the programme’s underlying principles?
3. The speed of the introduction of Modernising Medical Careers has seen the majority of the principles ignored.

4. The BMA thinks it is utterly unacceptable that only two of the seven pillars remain standing. These are that training is service based and quality assured (by the Postgraduate Medical Education and Training Board). Through expediency, the other five have fallen by the wayside. Most concerning is the loss of the pillars stating that training should be trainee centred and flexible.

5. The concerns and needs of trainees have been ignored. Corners were cut despite several warnings from the BMA’s Junior Doctors Committee. The supporting document ‘ A Call for Delay’ foresaw the problems that came to light. Unfortunately, these warnings were not heeded despite being repeated.

6. The most important principle that does not feature in MMC is flexibility. The possibility of movement into and out of training and especially between training programmes, a vital component of a settled and well-qualified medical workforce, has been eradicated.

7. Indeed, trainees have not been given the ability to change specialty – including a change to general practice - during their programme if they discover that the initial training path is unsuitable for them. A ‘one size fits all’ approach does not suit every specialty and separate basic and higher specialist training could be of practical benefit for junior doctors and the profession as a whole. These avenues have not yet been explored.

8. There are many other factors affecting flexibility. Pre-eminent is the need for doctors to be able to train flexibly (less than full time training). The demographics of the medical workforce continue to change with more and more doctors favouring a good work-life balance. Therefore, this is of utmost importance to them.

9. There is also a need for support for re-entry to training. Many doctors are now in fixed term posts, others are undertaking research and many are staff and associate specialists hoping to re-enter the training grade. Routes for these doctors have not been fully defined despite the original aim of MMC to ‘open up more opportunities for doctors in other career grades to re-enter training and become a consultant’ (reference 1). The continuing lack of such opportunity continues to be a major deciding factor in doctors’ opinions of the shortcomings of the Modernising Medical Careers approach.

10. In addition, the limitations for those looking to embark upon Out of Programme Experiences (OOPEs) have been increased as opposed to removed. There is now little possibility to do this during training which will inevitably detract from the value of academic pursuits, by which evidence based medicine is underpinned.

11. This year doctors have been forced to accept posts in locations away from their family or social networks. This may be due to the restriction on application choices, accepting a lower offer for fear of not gaining a post in their preferred Deanery. The ability for doctors to move location during training for personal reasons has not been fully accommodated.

12. In order to reintroduce the original principles the BMA proposes:

• The ability to change specialty during training
• Access to flexible training should be improved
• The creation of explicit pathways for re-entry to training
• Simple systems for those wishing to change geography during training

13. The BMA is also concerned that competency based assessment has not come to fruition. The ground work needed for a wholesale change in progression and assessment was not completed and the vision for a database of transferable competencies between specialties is far from being realised.

14. For a detailed description of how the BMA would envisage programme based specialty training programmes, please refer to the supporting document which includes the paper entitled ‘BMA JDC, The Shape of Specialist Training, 2004’ .

What are the strengths and weaknesses of the MTAS process?

15. The BMA supported the original idea of a national application process, whilst warning against possible issues that could arise using an un-validated computer system.

16. The benefits of a national system would allow:

• Applicants to complete one form
• Applicants to remain anonymous
• Applicants to access more opportunities at once
• National data to be collected
• National timetable to be implemented
• Reduction in local bias

17. The weaknesses of the MTAS system were:

• IT system could not cope with demand
• The IT system was not secure
• Some applications were lost / doctors could not submit applications due to the website crashing
• The matching algorithm for posts was never tested and therefore not used
• Long and short-listing criteria were not acceptable to the profession
• Online short listing functionality was not available at launch
• Plagiarism detection software was not available
• Many details were not finalised before MTAS went live
• Many details were changed after launch e.g. number of posts available, definition of one Unit of Application
• Academic achievements and potential were not properly accounted
• Academic Clinical Fellowship posts were made practically invisible which led in part to very low fill rates (57%).

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

18. The BMA urges the Department of Health to actively engage with the profession and to heed constructive comments and advice, rather than perceive any advice as criticism to be treated with suspicion. This echoes the recommendations of the Tooke Inquiry.

19. It is also important for the Department of Health to realise that wholesale change needs timely and careful management and piloting and that reforms cannot be forced through without sufficient and realistic timescales in place and without the buy-in of all those involved in the process. The latter cannot be gained without the “breathing space” for reflection necessary for stakeholders to be assured of the efficacy of changes. At times, stakeholders have seen changes as expedient rather than being convinced of their worth by clear evidence and rationale.

20. Communication between the Department of Health and the respective departments in the devolved nations is vital. Policy decisions affecting all nations should be discussed in detail, and their implications fully acknowledged.

21. In addition, communication with applicants using multiple channels is essential; many doctors and stakeholders were often unaware of changes and/or information relating to the application process. This was compounded by the myriad of changes squeezed into an artificially compressed timescale.

22. A vital lesson is that the lines of accountability should be clearly defined. This prevents multiple conflicting decisions being made and also provides a contact for complaint or enquiry. Responsibility must be accepted.

23. Academic recruitment in 2007 was a failure in part because of the absence of a national co-ordinating body with the authority to provide information to candidates about posts, approve the application forms, devise shortlisting criteria and provide interview guidance. A detailed account of the problems and with academic training and lessons to be learnt about project management can be found in the BMA Medical Academic Staff Committee document entitled ‘Clinical Academic Training – a lost opportunity ’, which was submitted as part of the BMA’s evidence to the Tooke Inquiry.

To what extent has MMC taken account of the supply and demand of junior doctors and the number of international medical graduates eligible for training in the UK?
24. It is crucial that the training structure under MMC is aligned with transparent medical workforce planning. However, evidence of effective Department of Health workforce planning has not been visible where MMC is concerned.

25. This is highlighted by the fact that over thirty thousand doctors applied for less than twenty thousand training posts – the latter a figure that ebbed and flowed over the course of the recruitment round. The lack of clarity about numbers reinforced in applicants’ minds that the whole process was questionable.

26. The BMA believes that in order for the principles behind MMC to be achieved, training post numbers should be established through effective workforce planning, based on need and not artificially restricted on the grounds of affordability.

27. The BMA’s workforce modelling suggests that over the period to 2030, the demand for doctors will be broadly met with current planned medical school intake and levels of overall immigration into the training grades. This is dependent on the assumption that doctors in training grades progress to Certificate for the Completion of Training (CCT) levels, and have the flexibility to move between training and non-training SAS grade posts as required to stabilise demand and supply for training and career posts and choice. The current training options put forward by the Department of Health make it likely that UK graduates will not all be successful in obtaining specialist training posts. This would result in a significant loss of investment which the BMA puts at £265,000 per doctor. No plans are apparent to allow for those graduates who fail to achieve specialist training posts to achieve skills and experience which would enable them to follow rewarding careers in medicine and safeguard the taxpayer’s investment.

28. If it becomes a reality that the projected output of UK medical schools will not all be successful in obtaining specialist training, the undergraduate and post-graduate education environment should be closely studied to make sure that medical graduates have all the skills required to compete in the wider job market in order to retain their skills in the UK.

29. The impact of immigration of doctors from the EEA has simply not been accounted for or assessed in this process.

30. The BMA’s policy on International Medical Graduates is clear; doctors that have been working in the NHS, with HSMP visa status, should be assessed on merit and not on immigration status when applying for posts. It is also the Government’s responsibility to highlight the decreasing opportunities available to International Medical Graduates prior to them coming to the UK.

31. The recent change in immigration law has affected many doctors; it was appalling that the Government ‘offered no opportunity for organisations representing affected doctors to communicate their views about the changes, and failed to comply with its duty to examine the race relations issues involved’, as stated in the High Court ruling on 9 February.

32. The change in this law caused extensive confusion for International Medical Graduates applying through MTAS and despite requests from the BMA, clear guidance for this group of applicants was not forthcoming until very late in the day. Even then, the guidance was open to interpretation by individual Deaneries. The current proposals to clarify Department of Health guidance, published on 8 October 2007, “Modernising Medical Careers (MMC) England Recruitment to foundation and specialty training - Proposals for managing applications from medical graduates from outside the European Economic Area” have been given a 10 working day response time in consultation. This is unacceptably short; such compressed deadlines suggest that the Department of Health have not learnt from the experiences of the last two years. Representative bodies such as the British Medical Association have no time to consult those affected, and this reinforces that the lack of reflection referred to above persists.

To what degree will current plans for MMC help to increase the flexibility of the medical workforce?
33. The Tooke Inquiry established that the main paths for flexibility have not been initiated.

34. It is worth noting that the amount of flexibility present within the medical workforce can be dictated by NHS Employers and, for this reason, full engagement of stakeholders is required. This is particularly important in the case of flexible trainees where there has recently been a downturn in the numbers appointed.

35. It is important to note that wider workforce issues are present here and so in addition to the suggestions made for improving flexibility in training for junior doctors, the impact on consultants, GPs, Medical Academics and staff and associate specialist (SAS) doctors should also be at the forefront of discussion. This impact is yet to be assessed, despite wide acknowledgement that junior doctors training cannot be considered in isolation. This has had a specific impact on the SAS contract negotiations.

Please comment on 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
36. The BMA is disappointed that Royal Colleges have not finalised work on transferable competencies and noted the problems caused by the late submission of some specialty curricula and person specifications. Despite promises that work is ongoing, as yet there is little evidence of competency assessment methods or robust specialty specific selection tools. In addition some conflicting stances on workforce planning have exacerbated the numbers of FTSTAs in some specialties.

37. Whilst acknowledging the very tight timescales and high demands placed on Deaneries the BMA is concerned that many used local interpretations of guidance to different extents. This had adverse effects on applicants with multiple job offers, those applying within short deadlines for Round 2 posts, academic applicants and international medical graduates with HSMP and was not sufficient to cope with the demand of arranging the interviews and answering applicants’ queries. The provision of careers guidance was also sorely lacking despite acknowledgement that this was desperately required. It has also been noted that deaneries were often inaccurate with regard to job descriptions and in some cases the allocation of rotations within a Unit of Application lacked transparency.

38. Applicants also complained that deaneries did not provide accurate job descriptions for posts and many felt they did not have sufficient information with which to make a very important decision. This led to a non-transparent approach to allocation to rotations within Deaneries. Despite the problematic implementation placing exceptional strain on applicants, deaneries were reluctant to introduce relaxed inter-deanery transfer schemes. A job transfer scheme was introduced but this was very rigid and it was doubtful that this assisted more than a handful of applicants.

39. The Postgraduate Medical Education and Training Board (PMETB) has been noticeably distant from the introduction of MMC, despite their compulsory involvement to reward or reject post approval. However, it is acknowledged that lack of information on the number posts by the Department of Health made even this task exceptionally difficult. It was hoped that PMETB would provide leadership on the standards of selection to specialty training.

40. Strategic Health Authorities were also removed from the process, it was also noted that employers lacked their support when the problems of MTAS emerged.

41. NHS Employers also contributed to the confusion by issuing guidance contrary to ministerial promises. This strengthens the requirement for consistent messages and improved mechanisms for communications.

42. As discussed above, and extensively in the Tooke Inquiry, the Department of Health has many lessons to learn from this episode. If the good will and morale of the profession is to be restored, our substantial, constructive and public warnings must be heeded and the involvement of the profession in any further discussions on subjects which affect us must be paramount.

For further information, please contact the Parliamentary Unit:
Email: parliamentaryunit@bma.org.uk

Reference:
1. Section 3.56, Unfinished Business: Proposals for Reform of the Senior House Officer Grade, 2002