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The British Medical Association’s response to the Sir John Tooke Modernising Medical Careers Inquiry

June 2007

Thank you for inviting the BMA to contribute to the Review of Modernising Medical Careers (MMC). We are grateful for the opportunity to clarify the views of our members on the future of medical training. The BMA has developed a substantial amount of policy in this area since 1999, but acknowledges that due to the ever evolving situation and disastrous implementation of the new training grade there has been a shift in opinion amongst the profession.

The response to the BMA’s survey, although small (4.1% (2225) of the 54600 BMA members emailed), highlights conflicting opinion with regard to the current reform. The changes proposed under MMC far-reaching and fundamental to the medical profession. While there are many benefits of a revision of training of doctors in the United Kingdom, there are important risks to take into account when making such a wholesale change to training. Thus it would have been expected that consultation with the profession to ensure the success of MMC would have been at the forefront of its implementation. However, it is important to recognise that the disastrous implementation of MMC this year has demonstrated the cost of ignoring the profession on issues that affect it. It is impossible to introduce such fundamental reforms to medical training without the support and understanding of the NHS as a whole, and doctors in particular, and it is to this end that the BMA demands the Departments of Health have an open and transparent dialogue and act on the grave concerns of the profession when reforming aspects of doctors’ professional lives.

The BMA has fully supported the ORIGINAL principles of MMC. However these principles, initially cited in Unfinished Business - have been transformed into a severely restricted version of MMC by the government in its haste to implement MMC over the course of one year. 51% of those surveyed by the BMA remain unconvinced by them.

The original proposal was for a phased introduction of MMC to ensure its success, without jeopardising the training of doctors. Many of the current problems would have been reduced or avoided if this principle (similar to the introduction of the Calman reforms) had been followed. Thus it is important that we revisit, reaffirm or renew the original principles in order to gain optimum improvements in postgraduate medical training for the future.

We will refrain from making extensive comments on the Foundation Programme application process for which a separate review involving key stakeholders, including the BMA, took place on 10 May 2007. The aim was to consider the issues that had arisen during the 2006/07 application process and develop improvements for the next round of applications. Following this review the revised process for MTAS F1 is currently being developed as it will need to be in place in good time for the next round of applications in Autumn 2007.

Therefore, this response will cover:

• recruitment and selection to specialty training
• training
• workforce considerations.

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Recruitment and selection to specialty training
The BMA has constantly pressed government to engage with the profession. The Junior Doctors Conference warned in 2004 that MMC was not ready for implementation and that further planning and discussion with the profession was required. As a direct result of constructive warnings from the BMA such as this, the Department of Health (England) saw fit to exclude the BMA from the writing of the Gold Guide for Specialty Training and the BMA’s membership of the Selection to Specialty Training Group . Later on in the process, the BMA's membership of the Selection to Specialty Training Group was withdrawn.

The current implementation of entry into specialty training was not fit for purpose as it directly contravened PMETB’s stated requirement that processes for recruitment, selection and appointment into specialist run-through training programmes should be open, fair and effective.

The fiasco that was the selection to training process this year must never happen again. The detrimental effect it has had on the morale of the whole medical workforce is immeasurable. Despite constant and consistent warnings from the BMA (JDC's document The Case for Delay ) , valid concerns with regard to recruitment and MMC as a whole were ignored. Even if recruitment had been deemed successful, vital components of training and assessment are yet to be finalised.

It is no surprise that the profession has currently lost confidence in any form of online application system , while the use of traditional CVs is fully supported .

Methods for recruitment and selection have been investigated by the BMA (BMA report Selection for Specialty Training) and the report was made available to the COPMeD Selection Group in May 2006; it is agreed that selecting trainees is a complex task, one which should be thoroughly investigated for effectiveness and efficiency. This will need to be the case for future recruitment episodes, whilst maintaining the anonymity of applications to prevent any discrimination or bias.

1. Recruitment to Specialty Training needs wholesale reassessment
2. The application process requires full and recognised input from the profession, which must include trainees (potential and existing) and assessors

Training
It is unacceptable that due to its rushed implementation the seven pillars of MMC - go to the MMC document The Next Steps now have been sidelined in the introduction of Specialty Training. These stated that training should be:

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

3.The principles above require further exploration, but must be a basis for the post graduate training of the future

Whilst the principles outlined above continue to have support from the BMA there is a need to reinforce, review and better define them to start to win back the support of the profession. We must ensure that the foundation of the future of post graduate medical training is based on clear professional support and best evidence for producing the highest calibre of career grade doctor for the future.

Competencies
It is important that competencies play the leading role that was originally envisaged. However, the minimum time in a given specialty or subspecialty should not be reduced. Indeed, in some specialties, it is possible that training may need to be lengthened as the pressures of EWTD come to bear . We call on the Royal Colleges in co-operation with PMETB to guarantee that examinations and assessments are appropriate, valid and reliable.

The current status of competency-based assessment is at best in a developmental stage and at worst non-existent. It is acknowledged that transferable competencies exist between specialties and this is seen as a vital element to enhancing flexibility (see below). There is clearly a huge volume of work to be done to ensure that competencies are identified, mechanisms for assessment of competencies and transferability of competencies are agreed and their equivalence or superiority to College examinations demonstrated in such a way that will satisfy the profession and be safe for patients. This work should also assess and define the necessary competencies for trainers and aid identification of adequate time, resources and remuneration for this training to be delivered with maximum efficiency and thus benefit to trainees, the service and patients. The BMA must be involved in the necessary collaborative work.

4.The BMA must be involved in any further work with regard to competencies

Flexibility
‘Flexibility of careers, of specialties and of geography will be enhanced and not lost.’ ( BMA document An Integrated Training System)

It is important to note that an original tenet of MMC was that training should be flexible. Contrary to current interpretations, trainees should not be forced into a career choice early, but be 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 (hence the focus on individual training programmes in Unfinished Business ). A ‘one size fits all’ approach does not suit every specialty and separate basic and higher specialist training will be of practical benefit for junior doctors and the profession as a whole.

The BMA supports the concept of a formal minimum two year period of 'core training' following the Foundation Year 2, followed by a competitive entry into higher specialist training at ST3 (or ST4 for paediatrics and psychiatry) in appropriate hospital specialties. There is a clear need for transferable competencies that are common between specialties to enable a trainee to transfer between programmes. The Royal Colleges must address this urgently. It is vital that a trainee shall not be forced to ‘start again’ in a new specialty and be required to undergo a second training period gaining skills that they have already obtained in the previous specialty.

This approach would be inefficient and demoralising and is unnecessary. Instead a trainee should be able to transfer competencies gained in one specialty either to start at a suitable level in another or to have shortened training in the second specialty taking account of skills and competencies already obtained. Entry at ST1 level into a few broad streams with gradual focussing over time into specific specialties, as proposed by the BMA (BMA document the Shape of Specialist Training ), would have helped deliver this necessary flexibility if the Colleges had had the time and resources to work together to deliver appropriate curricula.

A second aspect of flexibility is that of time. There is increasing demand for flexible training, or less than full-time training. With increased emphasis on work-life balance, and a workforce with changing demographics, it is of increasing importance that the service recognises, plans for and accommodates this need in its training system. The BMA recommends that a defined quota of run-through training posts should be set aside for flexible trainees.

Re-entry to training is another consideration that has fallen by the wayside. It was anticipated that MMC would ‘open up more opportunities for doctors in other career grades to re-enter training and become a consultant’ . This would also allow those allocated to Fixed Term Specialist Training Appointments, those in staff and associate specialist grades, those undertaking research, those taking time out of training for personal reasons and those with overseas experience to re-enter training at the appropriate level (there are also other options for research entries into Specialty Training, see Clinical academic training: a lost opportunity). FTSTA applicants would need to be able to compete for a run-through post in open competition, whereas those in research will have the ability to return to their stand alone NTNs.

It is also important not to forget those that take time out of training to gain out of programme experiences, it is essential that the ability to do this throughout training is not lost as this will detract from the value of academic pursuits, by which evidence based medicine is underpinned.

The flawed MTAS system has produced a sizeable cohort of doctors who are demoralised by the prospect of limited or non existent opportunity to return to training in the future. This must be resolved by creating more entry points at a higher level than ST1 .

Perhaps one of the most important aspects of flexibility is geography. It is important that trainees have a stronger influence on where they decide to train, and where they wish to continue their training. With particular emphasis on this recruitment period, inter-deanery transfers should be facilitated wherever possible. This is more important now as training contracts will span several years.

5.The ability to change specialty during training must be introduced
6.A database of transferable competencies must be formed
7.Flexible training must be made more accessible to trainees
8.Explicit pathways for re-entry to training must be introduced
9.Accommodation must be made for those wishing to change geography during training

Streamlined training
When writing Unfinished Business, the Chief Medical Officer was aware of the restrictions that the implementation of the European Working Time Directive and the reduction of training hours would create. It is important that new methods of training are implemented to ensure that this is feasible. It is vital that the output of training results in ‘fully-trained specialists with a wide range of skills more closely attuned to the current needs of the NHS’. The BMA believes that those with CCT should be appointed to substantive general practice or consultant posts. As has been stated in other fora, the BMA remains strongly opposed to the development of a sub consultant grade. The results of our recent survey (81% of respondents against the introduction of sub consultant grade) and extensive debate on this issue confirm that this view is also supported by the majority of the profession.

Another original component of MMC was its seamless progression, in other words, a removal of the ‘bottlenecks’ so evident in the SHO grade . It has long been agreed that it is not productive to train a doctor in a specialty where there is no opportunity for career progression. There has always been a tendency to recruit more SHOs for service provision than there are SpR rotations available and provisions for those trainees must be made for the duration of the transition period. The idea that successful completion of run-through training will lead to the award of a Certificate of Completion of Training should be preserved (e.g. the number of annual run-through training posts should match the anticipated service need for consultants (and GPs) on completion). This requires a fundamental improvement in workforce planning that needs urgent review and action, 90% of doctors who responded to the BMA survey stated that this must happen if a reform of the SHO grade is to be successful.

10.Training methods must be revised if the training timescale is to be amended
11. The output of training must result in fully-trained specialists with a wide range of skills more closely attuned to the current needs of the NHS

Careers advice
Regardless of earlier warnings and calls from the BMA, careers advice for doctors has not improved. It is appalling that only 24% of doctors feel that they have received good careers advice. This year, resources were made available for deans to provide career guidance for F2 doctors but not for SHOs, a group that had at least a similar need and arguably a greater one for good quality, sensitive careers counselling. If many doctors are expected to make important career decisions at an earlier stage it is vital that they are given the support and information that they require. This will prevent individuals wasting their time, and the resources of the deanery, on unsuitable/undesirable training. The BMA continues to call for appropriate and timely careers advice for medical students and post-graduate doctors alike.

12. Appropriate and timely careers advice must be readily available to medical students and post-graduate doctors

Workforce considerations
General Practitioners
For the most part the recruitment of GP trainees this year was not as problematic as other specialties; however, there was confusion over whether applicants were being offered posts on merit or preference. In future years it is essential that recruitment to GP ST posts is consistent with other specialties and the offer procedure is clear from the outset. It is also logical that FTSTAs should be available for those who wish to compete for GP run-through training in the future and that entry should be possible at ST2 and 3 for those with enough experience.

The principles underpinning GP training must be the same as those for hospital specialties and the need for flexibility (as detailed above) is paramount.

Consultants
MMC portrays consultants as both trainers and service providers. It was originally stated that the government is committed to a service that is increasingly delivered by trained doctors and that trainers should be supported and trained. If this is to be the case, particular attention needs to be paid to the changing role of the consultant. Increasingly the BMA feels we should be moving towards a consultant based, rather than consultant delivered service. This concept needs further development as part of the overall review of workforce planning for the future.

In this respect, consultants will need better support in order for them to teach more effectively. Therefore time must be allocated to consultants for them to adapt to and then deliver the new methods of teaching and assessment required by MMC. It is also evident that a distinction between time spent teaching and time spent delivering a service will need to be made. It must be explicit and acknowledged that the role of the consultant will change and this must be appreciated by the service.
Consultants must have realistic job plans, with sufficient time set aside for training and supervision of junior doctors. The current trend to reduce Supporting Professional Activities for purely financial reasons will have a very detrimental effect in this area.

The Health Departments have stated that they envisage that services will continue to be provided by consultants, and that a further increase in consultant numbers is necessary, but recent consultant expansion has been halted, even reversed in some areas/specialties, largely due to financial pressures. The BMA believes that in order for MMC to deliver its goals an expansion of the consultant grade is required. Furthermore, the increase in doctors in training means that there will be an increase in CCT holders. It is unacceptable that CCT holders be appointed to any grade other than consultant because the skills developed during CCT training will be wasted if the holders are appointed to a lower grade which does not allow them to develop their full potential in the interests of the NHS and patients. In addition, it is essential that the financial investment made in training these doctors to consultant level must not be wasted. The BMA is strongly opposed to the introduction of a new post-CCT sub-consultant grade. Patients deserve the best possible standard of care and this is best delivered through the gold standard of an expanded, consultant-based service.

However such a gold standard is in danger of never being achieved due to a number of factors:

• the severe financial pressures in the Health Service at present and diversion of NHS work into the private sector has led to a halt in consultant expansion and in some areas/specialties, there has even been a reduction in consultant numbers
• the European Working Time Directive means that even more service delivery must be provided by consultants
• demographic changes with a change in the gender mix of the consultant workforce, implies that more consultants will be required due to more part-time / flexible working of consultants
• increased pressure on the medical profession to further improve waiting time targets, etc, and
• the MMC process itself and the concentrated training of junior doctors flowing from MMC, which will divert consultant time away from service delivery and into teaching and training.

All of these factors will lead to a reduction in consultant time available for service delivery and can only be rectified by consultant expansion.

13. The increased workload of consultants must be acknowledged
14. Realistic job plans with Programmed Activities allocated specifically for training provision must be instigated
15. Planned consultant expansion is essential

Staff and Associate Specialists (SAS)
In addition to the considerations for re-entry into training there are others to be made for the SAS grade.

It was not an explicit intention of MMC that there should be profligate expansion of this grade on grounds of expediency or perceived cost savings. In fact, it was stated that the important goal of the NHS Plan 2002 was that more patients should be seen by a consultant.

It was noted that the position of the non-consultant career grade post could and should be transformed. It should be a post in which a doctor gains valuable service experience but from which many will be able to move (or move back) into specialist training should they so wish.

The stigma of this grade, which was discussed in Unfinished Business, unfortunately remains and has been exacerbated by the failure to deliver on the SAS contract and other aspects of Choice and Opportunity. If unsuccessful in gaining a training appointment, 66.4% of junior doctors would rather leave the NHS than take up such posts. Despite the dedicated hard work of SAS doctors their contributions often go unrecognised ( BMA document Hidden Heroes).

The original vision of MMC was to create a consultant-delivered service. This included the establishment of PMETB, part of the remit of which was to ensure that those doctors in the staff and associate specialist grades were given the opportunity to have their skills, training and experience assessed for equivalence with the standard set for the CCT. Further, 'Choice and opportunity' recommended that resources and formal infrastructures should be put into place to allow SAS doctors to return to the training grade at points commensurate with their level of training, skills and experience as well as to access short periods of top-up training to meet shortfalls in training needed to satisfy Article 14 applications. The idea of a medical workforce continually progressing towards the goal of the CCT/CESR gold standard of patient care and service delivery has been lost along the way.

It is imperative that particular attention is paid to the reform of this grade, in addition to the SHO grade, if MMC is to be a success. Unfulfilled recommendations and problems with current contract negotiations serve to undermine the role even further. Not all doctors will be in training at any one time, and therefore significant steps need to be taken to alleviate the stigma and make this role a more attractive and realistic career option.

16. Opportunities for SAS grade doctors to have their skills, training and experience assessed must be facilitated
17. Formal infrastructures to allow doctors to return to training must be implemented
18. Significant steps must be taken to alleviate the stigma attached to the SAS grades

Academic Medicine
Clinical academic numbers actually declined by 12% between 2000 and 2004. In absolute terms, the clinical academic workforce fell below 3,000 for the first time in 2005. Seen over a longer time period, the current academic workforce is only 83% of number in 2000. It is also an aging population with a 16% increase in the number of academics aged over 46 since 2004. There is thus an acute and ongoing requirement to train the clinical academics of the future. It is crucial that the numbers of clinical academic posts increase to satisfy the continuing need.

The BMA recommends that academic advertisement should be outwith the Specialty Training appointment allocation and has produced a supporting document that acknowledges the problems brought about by MTAS and discusses the future of academic recruitment and selection.

19. Clinical academic numbers and recruitment must be addressed
20. Advertisement of academic posts should be outwith Specialty Training allocations

Changeover date
It is of grave concern that the intention was/is to have a single changeover date for trainees (1 August). As the BMA forewarned this year, in future there should be a staggered start date for the benefit of all NHS staff, trainees and patients alike. Significant planning should be initiated now for 2008.

In initial discussions it was suggested that there would be two recruitment episodes per year, the BMA would support this idea as this would reduce the pressure on the service and allow more frequent opportunities for those unsuccessful in their application.

Workforce planning
It is crucial that the training structure under MMC is aligned with medical workforce planning. Medical workforce planning is about making sure there is the right number of doctors at each level to meet the health and health care needs of the general population and train future doctors. Medical workforce planning is complex given the length of training for a doctor, among other factors; therefore it is essential to maintain a link between the training structure and posts available and the number of highly skilled doctors required to lead and deliver health and health care services in the future.

In order for the principles behind MMC to be achieved, training posts at ST1 level and beyond should be aligned with the number of consultant and GP principal or equivalent posts required, established through effective workforce planning, and not artificially restricted on the grounds of affordability.

BMA workforce modelling suggests that over the period to 2030, the demand for doctors (as implied by the Wanless review’s ‘fully engaged scenario’) will be broadly met with current planned medical school intake and levels of overall immigration into the training grades, although a shortage of doctors is predicted for the medium term from 2010 to 2020. This is dependent on the assumption that doctors in training grades progress to 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.

Without a link between training posts and the required level of consultant and GP posts there would be an expansion of the existing SAS grade and/or the creation of a new sub-consultant grade, neither of which options were outcomes of MMC as originally proposed. The expansion of the SAS grade and/or the creation of a sub-consultant grade would dramatically change the dynamics of the medical workforce generating a system with a smaller proportion of highly qualified doctors to lead and deliver healthcare services and train the future medical workforce.

In addition, unless there is flexibility in the training system to allow doctors to move between speciality training and non-training service posts progression to CCT level would be delayed, if not made impossible, creating a gap between the demand and supply for CCT level doctors and going against the core principles of MMC.

21. Workforce planning must be dictated by the needs of patients and not affordability limitations
22. There must be a recognised and proven link between training numbers and the required level of GP and Consultant posts

Conclusion
With 46% of junior doctors considering working outside of the UK, the most important issue is the redesign of postgraduate medical training of the future, not only for trainees and trainers, but more importantly patients. Some aspects of MMC may be preserved, but others need extensive investigation. We need to see a step change from the discredited system currently perceived by the profession.

MMC is wrongly perceived as affecting only the training of junior doctors. However it is obvious that reform of the SHO grade will have a knock-on effect on the profession as a whole and thus these effects must be considered and accounted for.

Throughout discussions with the Department of Health the BMA has been appalled at the haste and manner with which MMC has been introduced. The original concepts of MMC have all but disappeared and what we are faced with is a re-badging of the SHO grade with a far more stringent restriction of choice and opportunity.

It is now essential that the original lessons from the reform of higher specialist training are learnt and that the five key principles are revisited, reinforced and reinstated –

• 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 core of this training must undoubtedly be flexibility and transferable competencies must be defined as soon as possible. The outcome of training must also continue to be fully trained specialists at consultant level, thus the need for consultant expansion.

The only way forward is for the future of post graduate training to be governed by a board of the profession that allows doctors to have significant influence over decisions that affect their professional lives. 92% of doctors want to be informed and consulted on future reforms – and this is their right.

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