PLANS FOR SPECIALTY AND GP TRAINING
The new structure
28. PMETB, the regulator for GP and Specialty training
programmes, began operating on 30 September 2005.[21]
One of PMETB's main initial tasks, carried out in conjunction
with the Royal Colleges and Specialist Societies, was to establish
new curricula for run-through training programmes across the 59
different medical specialties prior to the introduction of the
new programmes in August 2007. This work was accompanied by the
publication in June 2007 of the "Gold Guide" to specialty
training, the operational framework for specialty training produced
by the four UK health departments.
29. More detailed plans for the structure of the
new training system also emerged in this period. The new curricula
covered training from the first year of the new run-through programmes
(known as ST1 for hospitals doctors, GPR1 for GPs), through to
the completion of training, (typically at ST6 or ST7, or GPR3).
The first two years of run-through training, ST1 and ST2, would
be roughly equivalent to former SHO posts; while ST3 to ST7 training
would mirror Specialist Registrar posts. A number of Fixed-Term
Specialist Training Posts (FTSTAs) were created for doctors to
take up for one or two years during the transition to the new
system. The central role of Specialty Training within the new
system is demonstrated in the diagram below:
Figure 3: MMC training system: role of Specialty
training programmes
Source: Aspiring to Excellence (October 2007),
p.34
Plans for transition
30. All of the new Specialty and GP training programmes
were to be introduced simultaneously in August 2007. Recruitment
to Specialist Registrar posts was therefore curtailed from January
2007, with all SHO posts scheduled to end in August 2007. Existing
Specialist Registrars were given the option to assimilate into
the new system in 2007 or 2008.[22]
Doctors would enter the new training system at all levels, though
in 2007 the vast majority would come in at the lower levels, between
ST1 and ST4. No formal pilots of the new training programmes were
carried out prior to implementation.
31. To support the transition to the new system and
the major selection process needed in the first year, the Department
of Health set out plans in late 2006 for a nationally co-ordinated
selection process, known as the Medical Training Application Service
(MTAS) to run between January and August 2007. The MTAS system
would comprise two consecutive recruitment rounds and all candidates
would apply through an electronic portal. Candidates could apply
to up to four different training programmes and would be short-listed
using nationally agreed application forms and a national shortlisting
scoring system. Short-listed candidates would then be interviewed
and offers made to successful candidates after all the interviews
had been completed. Unfilled vacancies from round one would be
made available in the second round of recruitment and some candidates
would be offered one-year FTSTA posts, rather than run-through
training posts. [23]
Warning signs
32. A number of concerns were raised during 2006
from both within and outside the MMC programme about the lack
of progress on planning for implementation in 2007. The timescale
for developing the MTAS national recruitment system was short:
the development of the new computer software began in March 2006
and of the new national application form in May 2006, just a few
months before recruitment was due to begin. The development of
the national selection system was therefore given a "red"
risk rating by Departmental project managers from May 2006 onwards,
an indication of serious concern. The "red" rating remained
in place up to and beyond the start of recruitment in January
2007.
33. Further concerns were raised by the Junior Doctors
Committee (JDC) of the BMA, which issued a "Call for Delay"
in June 2006, arguing for the introduction of the new programmes
to be postponed for a year. The JDC re-iterated its call for delay
in October 2006, setting out a number of reasons not to introduce
the new Speciality training arrangements in 2007. These included:
- Serious concerns about the
MTAS recruitment process including the "worryingly short
timetable" for selection to take place. The JDC raised questions
about the short-listing process and warned that "the application
forms questions do not seem to be searching enough";
- "Deep concern" about the inflexibility
of the training structure due to be introduced in 2007, in particular
because of the application of the run-through training concept
across all specialty areas; and
- Predictions of "a shortfall" in the
number of available training posts compared with the expected
number of applicants.[24]
34. Revealingly, the BMA's concerns were shared by
the leaders of MMC itself. Professor Alan Crockard, National Director
for MMC, told us that he himself raised serious doubts himself
during this period about the readiness of the new systems. Professor
Crockard stated that his concerns were ignored by officials at
the Department of Health and that he therefore expressed his "total
frustration" with the planning for 2007 through a number
of other channels in late 2006:
We saw the situation unfold from fairly well
back; I had tried very hard to make this known to the SRO [Senior
Responsible Officer or Owner] to whom I was accountable in terms
of MMC, and to the DCMO [Deputy Chief Medical Officer]…from
October to December, I had actually spoken to the regulator, to
people from the Treasury, to the advisors to Ministers and to
the NAO about my concerns.[25]
Supply and demand
35. Further doubts about the transition to the new
training system were created by uncertainties about the likely
number of applicants and the number of posts that would be available.
The potential applicant pool would comprise not only those doctors
completing the Foundation Programme and those in existing SHO
and SAS posts in the UK, but also overseas applicants, both from
within and outside the European Economic Area (EEA). On 1 February
2007, it was announced that a total of 18,000 Specialty and GP
training posts would be available in England. Lord Warner, then
the responsible Minister, commented that:
We anticipate that there will be around 16,000
-17,000 doctors in England eligible to apply for these positions,
but we do not yet know how many doctors will apply from the EEA
and overseas.[26]
36. Fears about a possible shortage of training posts
in 2007 and beyond were exacerbated by the ongoing expansion of
UK undergraduate medical school places. Although the move to increase
self-sufficiency had begun in 2000, it was not until 2006 that
the Department of Health made attempts to restrict access to training
posts for doctors from outside the EEA. To this end, the Home
Office announced in March 2006 that arrangements whereby non-EEA
doctors did not require work permits to take up UK training posts,
known as "permit-free training" would be ended.[27]
37. The decision to end permit-free training, however,
which took effect in April 2006, did not resolve the problem.
As 2006 progressed, applications to medical training posts through
the Highly Skilled Migrants Programme (HSMP), an alternative entry
route for non-EEA doctors, rose sharply. In order to address the
spike in HSMP applications, the Department of Health issued guidance
to NHS employing organisations later in 2006. The guidance, which
stated that HSMP applicants could not be offered training posts
unless there was no suitable applicant from within the UK or EEA,
aimed to protect opportunities for the growing number of UK graduates.
38. The guidance, which would in effect limit opportunities
for non-EEA doctors to those in the least popular specialties,
was challenged in the High Court by the British Association of
Physicians of Indian Origin (BAPIO), a professional representative
body. BAPIO's case was heard in the High Court in December 2006
but no judgment was passed until February 2007. Thus thousands
of non-EEA doctors with HSMP status submitted applications when
the MTAS system opened in January 2007, even though the legal
status of such applicants remained unresolved.
Conclusions
39. The initial implementation of the Modernising
Medical Careers (MMC) programme went relatively smoothly through
the introduction of the new Foundation programme in 2005. As the
Department prepared for the subsequent reform of Specialty Training,
however, a number of warning signs indicated that all was not
well. Concerns were raised both within and outside the Department
about the inflexibility of the new training system, the inadequacy
of the new national recruitment system, and a possible shortage
of training posts. In spite of these issues, and heedless of the
warnings of the Royal Colleges and of an official "Call for
Delay" by the BMA, the Department pressed ahead with its
plans for wider reform in 2007. We recommend that the Department
ensures that it heeds such warnings in future.
1 The Specialists Registrar post replaced the previous
Registrar and Senior Registrar posts. Back
2
Aspiring to Excellence, p.31 Back
3
Unfinished Business, p.4 Back
4
Ibid, pp.5-6 Back
5
Ibid, p.6 Back
6
The level of seniority and range of activities performed by SAS
doctors both vary widely. Some SAS doctors are trained to the
same level as consultants, while others have no more formal training
than SHOs. Back
7
Department of Health, Choice and Opportunity, pp.1-4 Back
8
Ibid, p.5 Back
9
Ibid, pp.9-13 Back
10
The number of SHAs was reduced from 28 to 10 with effect from
July 2006. The number of PCTs was reduced to 150 with effect from
October 2006. Back
11
Aspiring to Excellence, pp.29-30 Back
12
A summary of the 254 responses to Unfinished Business was
set out by the Department of Health in a Consultation outcome
published in February 2003. The Department commented that "There
was little deviation from the view that the SHO grade was in need
of reform…" and that "The vast majority welcomed
the broad thrust of the proposed changes." Back
13
Department of Health, Modernising Medical Careers, pp.2-6 Back
14
Department of Health, MMC: The next steps, pp.2-6 Back
15
Ibid, p.7 Back
16
Department of Health, MMC: the next steps, p.2 Back
17
Department of Health, Modernising Medical Careers, p.6 Back
18
BMA, Foundation programme pilot schemes monitoring report to
the Junior Doctors Committee and the Medical Students Committee,
May 2004. Back
19
See, for example, An evaluation of four foundation programme
pilots in Kent, Surrey and Sussex by Graeme Dewhurst, Pam
Shaw and David Wood published in the British Journal of Hospital
Medicine on 1 January 2006. Back
20
See http://www.foundationprogramme.nhs.uk/pages/home/deaneries-foundation-schools
for more information. Back
21
See Preparing doctors for tomorrow: about PMETB for more
information. Back
22
Department of Health, A guide to postgraduate specialty training
in the UK, p.13 Back
23
See MMC-Statement on recruitment and selection to Specialty
Training programmes in 2007 Back
24
British Medical Association Junior Doctors Committee, "Call
for Delay", October 2006 Back
25
Q 266; the terms Senior Responsible Owner and Senior Responsible
Officer are used interchangeably by the Department of Health Back
26
Department of Health, 18,000 new specialty training opportunities
for 2007, 1 February 2007 Back
27
Ev 19 Back
