Recruitment to specialty training: Proposals for improvements in 2008
25 September 2007
Response from the British Medical Association
The consultation document from the Department of Health to which this document is a response can be found here.
Introduction and general comments
The introduction of MMC specialty training was a disaster in 2007. Morale in the profession is incredibly low as a result, and it is with this in mind that the BMA believes that solutions to the ongoing problems with MMC in 2008 need primarily to take into account the needs of the young doctors directly involved and the medical profession as a whole. The primary role of the BMA is to represent the views of doctors in the UK, and it is important from the outset that this position is clear. The quality of patient care in the NHS will be adversely affected if selection to specialty training is not improved in 2008, and again from 2009 onwards.
The BMA welcomes the opportunity to respond to this consultation and to engage in constructive debate with other key stakeholders in order to design a workable selection process for specialty training in 2008 that commands the confidence of the medical profession. However, the options available in ‘Recruitment to specialty training: Proposals for improvements in 2008’ are unsatisfactory.
The BMA is under no illusion about the need for compromise in designing selection to specialty training for 2008, but believes that all possible routes for selection should be explored. The Programme Board should strive to achieve the best solution possible in the existing context of gross mismatch between the number of junior doctor applicants and the number of training opportunities. The Board should choose the route that carries the lowest risk of worsening the morale of a group of doctors who, during the 2007 selection process, continue to feel badly mistreated and disenfranchised, and that there is a significant risk of many mistakes being repeated in 2008. In addition, selection must be designed to allow the best candidates to be appointed.
Timetable for selection
The BMA is aware of the time restrictions for selection to specialty training 2008 and understands that decisions need to be made in the near future. It would therefore be useful to decide in advance upon the entire timetable for 2008, rather than just the start and finish date. The BMA believes that a UK-wide, co-ordinated timetable for applications and offers with a final common acceptance date is essential. The co-ordination of interviews by specialty between deaneries was helpful in avoiding clashes in 2007, and should be repeated where possible.
The BMA welcomes early forward planning for 2009 and is pleased to represent the views of its members at the stakeholder meetings. It is also encouraged by the aim of holding local workshops to involve doctors at grass roots level and would welcome these being held across the UK. The need for piloting any new ideas cannot be emphasised strongly enough.
Context
The BMA is concerned to see the assumption in the paper that the competition ratios for specialty training may be as high as 3:1 (and will be even higher in the more popular specialties) and would be interested to see the rationale for this assumption. The BMA fears that this ratio may be significantly higher for those wishing to enter above ST1 level, particularly in some specialties. The requirement for a significant number of entry points at these higher levels should be recognised, and management of the number of entry points should coincide with the demand for them e.g. ensuring that the number of posts available permits fair competition across all entry levels, which did not happen in 2007. The junior doctors already part way through their training (e.g. the former SHO cohort) must have equity of access to specialty training with Foundation doctors.
Short listing
The differences between selection to ST1 and ST2 and above are great enough to merit a different selection method for ST1. Short listing for ST2 and above should rely more heavily on experience and motivation in the specialty using appropriately weighted objective measures announced well in advance.
The BMA does not approve of any of the short listing options discussed in the document and suggests that all short listing should be performed by local deaneries in conjunction with specialty SAC/STC committees (for ST3 and above) as part of a UK-wide application timetable. In addition, any new selection tools, including knowledge tests and OSCE-style assessments, should be piloted this year but should not influence selection unless or until proven to be accurate, robust, reliable and valid. If these methods are used they should be run alongside the standard recruitment process and should not be the only method for recruitment. A key lesson from the events of this year is that major changes must not be introduced without proper testing and piloting.
In addition, it is important to clarify that the current test used for GP is an aptitude test, rather than a knowledge test.
A national application form with a common core and specialty specific questions is likely to be the more acceptable option for applicants in 2008. Attaching a CV to the application form should also be a requirement.
3.6 Number of preferences
The BMA believes that the number of applications permitted by any one candidate should be essentially unlimited. The restriction on applications to four preferences in 2007 was very unpopular and widely considered as something imposed for operational reasons that disadvantaged all candidates.
The option of offering one interview, where the scores would be passed on to other deaneries (option 3) is strongly opposed. In light of the problems encountered in 2007, junior doctors would not welcome the unnecessary pressure that would amass at the single interview.
The BMA believes that reducing the size of UoAs and removing the limitations on the number of possible applications is the best forward for 2008.
Applicant ranking of preferences will only be necessary if an offering system based on preferencing can be agreed; otherwise there will be no benefit for candidates to preference their options. However, an applicant who has ranked a post highly should not be offered it over an applicant who has given the same post a lower ranking but who performed better in the selection process. Those carrying out the interviews must not have access to an applicant’s preferences.
3.7 National computer system or local deanery’s own system
The BMA was dismayed at the problems caused by the MTAS system in 2007 and requested an extension to the deadline for applications several times. It also highlighted in its ‘Call for Delay’ the need for a back up system should problems be encountered. This back up solution was never discussed in depth, hence the problems this year. However, the BMA would support a national computerised applications portal for applications to specialty training with the strict proviso that it is delivered on time, having been tested to destruction and has a proven manual back-up scheme in place that can be quickly implemented.
3.8 Size of units of applications
The BMA would like to see the size of UoAs reduced. Applicants will have more control over their location whilst not impacting on or increasing the workload involved in recruitment. The very large units of application such as London/KSS and Scotland render the concept meaningless when flexibility and geographic stability were meant to be a positive result of the MMC agenda. These two units in particular, need to be re-evaluated in the light of experience.
It is imperative that the number of posts available should be defined as early in the process as possible.
3.9 An integrated national timetable
As discussed earlier, the BMA believes that a UK-wide, co-ordinated timetable for applications and offers with a final common acceptance date is essential. This prevents the ‘stick or twist’ situation for candidates that arose in 2007 and will enable more junior doctors to obtain satisfactory posts in that recruitment round.
3.10 Other issues
As stated in the consultation document, the JDC believes that the time limit for entry to ST1 should remain. However, the limits on experience for ST2 and above should be relaxed or removed altogether. This would allow those placed in FTSTAs, Staff Grade doctors and those in research posts to re-enter training at the appropriate level. It would then be down to those longlisting and the interviewing panel to assess the suitability of the candidate. This cannot be assessed on a written application.
The idea of a single deanery longlisting all applications is not necessarily a bad one. The criteria would have to be factual, clearly defined and agreed by stakeholders in advance. More complex decisions would need to be made at local level by those shortlisting e.g. decisions on experience time limits.
Part 2: the offer to applicants 2008
Staggered start dates.
The BMA supports multiple start dates during the year for 2008 as detailed in its response to the Tooke Inquiry. It believes this would introduce additional opportunities for doctors to enter training and help to alleviate excess pressure on the service as a whole. However, care must be taken to ensure that those leaving the Foundation Programme or FTSTA posts on 31 July 2008 are able to continue in employment whilst waiting for their StR posts to start later in the year.
3.15 Transferable competencies
The BMA has always fully supported the need for transferable competencies and believes that it is the lack of these that has restricted the flexibility within Modernising Medical Careers. The BMA would welcome the publication of the work already done in this area, as it has yet to see results from medical royal colleges and specialty groups to date in defining essential transferable competencies.
3.16 Fixed term specialty training appointments
Doctors in fixed terms specialty training appointments in 2007/08 will only have a viable future as fully trained specialists if there are adequate entry points for run-through programmes available at ST2 level and above. See our response to 3.17 for further detail on how this could be made possible.
3.17 Run-through training and the possibility of “uncoupling”
Everyone appointed to run-through training in 2007 must have this appointment honoured. We are in agreement with the Programme Board’s stated position on this matter.
The BMA does, however, accept that run-through training may not be appropriate for all specialties. However, uncoupling is also not suitable for all specialties and may recreate the pre-NTN bottle-neck that MMC attempted to remove. It must be clearly understood that any move to uncouple run-through training must not lead to recreation of this bottle-neck and that the number of core and higher specialist training posts should closely match. Good workforce planning is essential to ensure adequate numbers of consultant and training posts in the future. We must realise that the “one size fits all” solution is flawed and flexibility must be allowed to specialities to select and train as is best suited for them.
The BMA supports the so-called Inverted Pyramid model in workforce planning, as detailed in an appendix to BMA Scotland’s programme board discussion paper (details available to logged in users on the BMA website MMC forum), which is tailored to the needs of each specialty and locality. This means that once appointed to a run-through post, trainees should progress to CCT, subject to satisfactory progress. There should also be ongoing recruitment to levels above ST1, with a number available at each level for open competition and this should be supported by robust workforce planning. In addition, returning researchers (junior doctors who started their MD/PhD before 2007 and are due to complete 2006-2010/11) must be allowed to compete for ST3 entry in any system, open or closed. Their numbers are small, making them relatively easy to accommodate. The issue here is fairness and equity; these doctors made their career decision to do their postgraduate qualification before MTAS/MMC was implemented, and should not be disadvantaged because of an arbitrary decision to close/open ST2/ST3 competition in 2008. Medical school intake should also be included in any workforce planning model.
Questions to be resolved
It is essential that forward planning is instigated immediately if uncoupling is to take place; concrete plans for those displaced from training in open competition must be defined. Workforce planning should ensure co-ordination between the numbers of those trained and those progressing to the consultant and GP register to prevent doctors’ training being terminated early without reason as we have seen in 2007.
Conclusion
Whilst we welcome this consultation process, the BMA feels that we are still nowhere near a satisfactory solution for 2008. There is much work to do, and we look forward to working with our partners in the best interests of doctors and patients, on the important issue of training the future medical workforce.