The Government’s response to Sir John Tooke’s inquiry into Modernising Medical Careers
March 2008
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.
Introduction
The BMA welcomed Sir John Tooke’s independent and professionally-led inquiry into Modernising Medical Careers (MMC). The BMA views the recommendations contained in the report as an important package that the medical profession can move forward with but it is essential for the Government to play its part in light of the report. While there are some areas of detail in Sir John Tooke’s report that need further, careful consideration, speedy action on the key recommendations will deliver better education and training for doctors, and will be beneficial for the NHS and the public.
The inquiry has resulted in a damning indictment of the failings of training reforms. There must be better workforce planning, and far greater value placed on the crucial role of doctors within the NHS. Whilst the report charts a way forward, the huge problems facing doctors currently going through the system must not be ignored. There is massive competition for training posts, and many excellent doctors will not be able to progress in their careers because of poor workforce planning.
On February 28, the Department of Health in England published its official response to Sir John Tooke’s inquiry. It has agreed to implement many of the recommendations but delayed making a decision on several others. In response to the report, the BMA is ready and willing to play a leading role in developing a mechanism for providing coherent advice on matters affecting the entire profession. The BMA is already contributing to the MMC Programme Board (reference 1) and Lord Darzi’s Next Stage Review.
This briefing paper highlights the main recommendations in the Tooke report.
Clarification of policy objectives
The BMA has been dismayed that the original principles cited in Unfinished Business (reference 2) were discarded during the implementation of the new training system and concurs that any future changes to the structure in postgraduate medical education should be aligned with agreed policy objectives and guiding principles. The BMA agrees that there should be an ‘aspiration to excellence’. The Government, in response to the Tooke report, agrees with the recommendations on the clarification of policy objectives.
The role of the doctor
This recommendation is paramount if a successful balance between service provision and training is to be achieved. The BMA agrees that the role of the doctor needs to be defined by the medical profession, supports continuing debate and is currently facilitating further discussion within the profession on this subject. The Government has indicated that it accepts in principle the Tooke report’s recommendation on the role of the doctor.
Policy development and governance
The importance of UK-wide policy on medical education and training structures is vital and it is agreed that all four Departments of Health in the UK and the four Chief Medical Officers must be involved in any moves to change medical career structures. The Government accepts the recommendations in principle noting that precise arrangements for doing so will depend on decisions on the proposed creation of NHS:MEE and the outcomes of consultations by Scotland and Wales on their approach to taking forward the Tooke report’s recommendations.
Workforce planning
There is an urgent need for a coherent and accurate model of medical workforce supply and clearly the way forward to produce such a model needs to be debated. It is essential that the BMA is involved in the process of developing the content of higher speciality training and workforce planning – in addition to input from the royal colleges, employers and medical workforce advisory machinery. The changing demographics of the medical workforce and the demand for part-time and flexible training must also be recognised. The Government accepts the recommendations in principle but points to related work in Lord Darzi’s Next Stage Review that is also considering workforce planning.
Medical professional engagement
The BMA acknowledges and supports the desire for a united professional voice. For example, the BMA seeks to harmonise professional messages to the Government through its participation in the MMC Programme Board and the Joint Medical Consultative Council (JMCC). (Reference 3)
The establishment of ‘time-limited Boards’ for specific issues as they arise have been particularly effective. The MMC Programme Board, which was created in 2007, has been extremely beneficial. The BMA will look to provide a conduit for all members of the profession to voice their opinions, possibly through a joint forum. The Government has accepted in principle that the medical profession should have a mechanism to facilitate coherent advice on profession-wide matters although it feels this particular recommendation has been directed to the medical profession. However, the Government has indicated that it will give a fuller response on this recommendation after the proposal for NHS: MEE has been further considered.
Streamlining regulation
The BMA supports, in principle, the concept of streamlining regulation, such that the Postgraduate Medical Education and Training Board (PMETB) is assimilated in a regulatory structure within the General Medical Council (GMC). However, this recommendation is only supported on the basis that the current financial arrangements for the individual process should be improved and that the newly amalgamated body has appropriate professional representation. The Government has accepted the Tooke report’s recommendation and has indicated that it will merge PMETB with the GMC at the soonest possible time although the legislative process means that this will not be before 2010. The Government states that it will publish a timetable once a plan has been worked through.
The Foundation Programme
The BMA believes that the Foundation Programme gives junior doctors a core, generic two-year training programme on which they can build their specialist training. This will improve the quality of the medical workforce as it will enable better understanding of different fields of medicine as well as giving the doctors of the future a more complete set of all round medical skills. The Foundation Programme also offers early exposure to academic medicine, which is a vital to promoting academic careers.
However, there are issues with this format of training which require further assessment and discussion, such as the value of four month placements and the provision of teaching. We would hope the concept of the F2 year will be developed, and retained with ongoing improvement, rather than be completely lost due to issues with its implementation. Therefore, the BMA disagrees with Tooke’s recommendation 33, which seeks to abolish F2, under the proviso that there is a continuation of the assessment of the F2 year in particular.
The Government has agreed with reviewing the F1 curriculum but has stated that further consideration is needed on whether the employment linkage between F1 and F2 should be broken; whether F2 should be incorporated as the first year of core specialty training; whether at the end of F1, doctors will be selected into one of a small number of broad-based specialty stems; and whether there will be opportunities for competitive transfer between the core stems during years one and two.
Core and higher specialist training
The BMA has always supported the concept of broad-based training and therefore supports the notion of a three year core training programme followed by higher specialty training. However, this should not result in enforced open competition in order to move from Core to Higher training. There must also be multiple recruitment rounds for Core and Higher specialist training throughout the year. The BMA also agrees that further work on transferable competencies is essential. Within training there must be robust and tested transferability of competencies to allow the aspirations of a broader curriculum under core training, and to allow flexibility for movement between specialties as required for workforce planning and for career development and choice. There is an urgent need for the royal colleges to produce clear proposals on how this will be done.
The Government agrees in principle that royal colleges, specialist societies and the service should work together to provide modularised curricula for specialist training. The Government agrees that doctors should be allowed to interrupt their training for one year or longer by agreement to seek alternative experience that enhances their career contribution to the NHS, having regard to service need.
General Practice Training
The BMA supports the recommendation that the length of training in general practice should be extended to five years. However, our agreement comes with the proviso that the extension to training must focus on the GP curriculum throughout and must be relevant to their future GP career. Training to be a GP must be the primary focus. We would be concerned if GP training were to encompass three years in hospital with a service focus. In order for this recommendation to be successful it is essential that GP trainers are adequately supported and remunerated. The retention of GP trainers is of great importance when considering GP training for the future. The Government accepts that extending the length of training in general practice warrants serious consideration but states further work needs to be done to see how this recommendation could be taken forward.
Academic Training
The BMA supports early exposure to the potentials of a career in research/education. A tailored menu of entry points for Academic Clinical Fellowship posts at ST1 and higher should be offered to maximise opportunities for entry into pre-doctoral training posts, both to recognise that interest in an academic career can develop over time and that research in some specialties benefits from greater clinical experience. The Government welcomes and supports this recommendation.
Post Certificate on Completion of Training (CCT) careers
The BMA strongly opposes any proposed introduction of a post-CCT pre-consultant specialist grade and believes that a new grade is not necessary. It acknowledges that there are a number of factors which have resulted in the proposal for a new ‘specialist’ grade, but believes that these can be addressed by using the current structure within the NHS and through optimal utilisation of the 2003 consultant contract. The Government has agreed in principle that successful completion of higher specialty training will lead to a CCT, confirming readiness for independent practice in that specialty at consultant level. However, the Government has stated that this recommendation is being considered as part of Lord Darzi’s Next Stage Review.
Trust Registrars
The BMA is adamant that the key to de-stigmatising the staff and associate specialist (SAS) role is through provision of Continuing Professional Development and a new contract with improved terms and conditions – the importance of recognising and rewarding doctors in this grade cannot be emphasised enough. The Government has agreed with Tooke’s recommendations to de-stigmatise staff grade positions, rapidly conclude contract negotiations and acknowledged that satisfactory completion of assessments of knowledge, skills, attitudes and behaviours will allow eligibility for staff grade positions and higher specialist training.
European Working Time Directive (EWTD)
Sir John Tooke’s inclusion of a recommendation on the EWTD raises a number of important issues such as compensatory mechanisms and the separation of service and educational contracts. The Government has indicated in its response to Tooke that it will continue to seek amendments to the EWTD to address the ongoing issues from the SiMAP and Jaeger (European Court of Justice) cases. The Government says that this includes more flexibility over the timing of compensatory rest breaks (for missed rest) and ensuring that time on-call in the workplace (not spent on active duty) is not counted as working time. Needless to say, any changes to the EWTD will require negotiation and lobbying at a European level and there have been several abortive attempts to do this over the last few years. The BMA believes that further discussion is needed on this recommendation.
National Coordination: England (NHS: MEE)
Sir John Tooke recommended a new body in his final report to oversee training in England, effectively taking that power away from the Department of Health, and putting it back into the hands of the medical profession. Such a move would regain the faith of doctors and provide a better guarantee of quality and safety for patients. The profession also applauds the recommendation to ring-fence the budget for medical education and training.
The BMA, along with all the other medical bodies, believes that both of these changes are absolutely essential if we are to ensure high quality medical training in future. For several years now, trusts have been raiding funding set aside for professional education and training to meet deficits. This funding also pays for medical student placements in hospitals – an essential element of their education. Failing to protect it risks the standard of training for many doctors, and ultimately the future quality of patient care.
It is important that funding for training is ringfenced at trust level to ensure that doctors are trained to their full potential. Furthermore, there are suggestions that these funds could be diluted even more by spreading them more thinly across other professions. Doctors’ training should not be adversely affected by the Government’s reluctance to appropriately fund training for our fellow healthcare professionals. We hope that the Government will listen to the medical profession, ringfence the funding, and allow doctors in training to benefit. The Government has indicated that a decision on this will be taken alongside Lord Darzi’s Next Stage Review, which is due to report in June this year.
References:
1. The MMC England Programme Board oversees and makes recommendations to Ministers for the MMC Programme in England for 2008. It provides leadership to the professions and the service for the design, testing and implementation of the MMC programme and is accountable for changes made.
2. Unfinished Business, the Chief Medical Officer's (CMO) report containing proposals for reform of the senior house officer (SHO) grade was published in 2002.
3. The Joint Medical Consultative Council brings together the organisations that represent the medical profession in the UK, including the BMA and the medical royal colleges through the Academy of Medical Royal Colleges.
March 2008
For further information, please contact the Parliamentary Unit:
Email: parliamentaryunit@bma.org.uk