Select Committee on Health Third Report

2  The gathering storm: 2003-2007

Box 1: Key events in the development of Modernising Medical Careers

August 2002 - Unfinished business (written by Sir Liam Donaldson, Chief Medical Officer for England) calls for reform of the Senior House Officer (SHO) grade.

February 2003 - Modernising Medical Careers (jointly published by the 4 UK Health Ministers) sets out initial plans for reform of medical training.

July 2003 - Choice and opportunity: Modernising medical careers for Non-Consultant Career Grade doctors (by the Department of Health for England) is published.

April 2004 - MMC: The next steps (jointly published by 4 the UK Health Ministers) sets out details of the new structures for medical training.

June 2005 - Curriculum and operational framework for Foundation Training published.

August 2005 - Start of new 2-year Foundation programme across the UK

March 2006 - End to "permit-free" training for non-EEA doctors announced

January 2007 - Start of recruitment to new GP and hospital Specialty Training jobs

June 2007 - Publication of "Gold Guide" to Postgraduate Specialty training

August 2007 - Start of new GP and Specialty Training jobs.

10. This chapter examines the origins of the Modernising Medical Careers (MMC) programme, the case for changing the postgraduate medical education system and career structure, and the planning which preceded the introduction of the new systems for Specialty and General Practice training in 2007. We look in particular at:

  • The rationale for the MMC programme, derived from problems affecting Senior House Officer (SHO) and Staff Grade and Associate Specialist (SAS) doctors, and other factors which influenced the programme, such as the need to comply with European Working Time Directive regulations ; and
  • How the principles established in Unfinished Business, the 2002 document establishing the case for change, were translated into a set of practical plans for reform, implemented through the new Foundation Programme, which began in 2005, and new Specialty and GP training programmes from 2007.

Rationale for change


11. The most recent significant reforms to the postgraduate medical training system prior to MMC took place during the 1990s and were instigated by then Chief Medical Officer Sir Kenneth Calman. The Calman reforms were initiated by the publication in 1993 of Hospital Doctors—Training for the Future and were mainly concerned with improving specialist hospital training. This led to the introduction from 1996 of Specialist Registrar posts with explicit curricula, regular assessments of progress, and limited to a maximum of seven years.[1] The reforms also introduced the Certificate of Completion of Specialist Training, awarded by the General Medical Council (GMC).[2] No changes were made at this time to the Pre-Registration House Officer and Senior House Officer (SHO) grades which preceded the new Specialist Registrar grade in the training system.

12. The shape of the training system following the implementation of the Calman reforms is shown in the diagram below:

Postgraduate training—pre-MMC

Figure 1: UK Medical training system following the Calman reforms

Source: Aspiring to Excellence (October 2007), p.32. See Glossary for details of abbreviated terms.


13. In August 2002, the Chief Medical Officer for England, Sir Liam Donaldson, published a consultation paper on medical training. The paper, Unfinished Business, described a number of problems experienced by some doctors in the junior training grades, and particularly at SHO level. In particular, Unfinished Business highlighted:

14. Unfinished Business set out five principles for the reform of the SHO grade: training should be programme-based, time-limited, broad-based to begin with, flexible and tailored to individual needs. To achieve this, the consultation proposed the introduction of a 2-year "foundation programme" to immediately follow graduation from medical school, followed by broad-based "basic specialist training programmes" in around eight different specialty areas, including general practice. Unfinished Business stressed that the new programmes should allow trainees the flexibility to leave and then re-enter training and should address the needs of non-UK graduates. [4]

15. The possibility of integrating the various training programmes into a single, unified training grade was also mooted in Unfinished Business. The report stated:

    The advantages of moving to a single training grade encompassing: foundation; basic specialist; general practice; higher specialist; and individual training programmes should be urgently explored. In such an arrangement doctors in training would move seamlessly through the grade subject to satisfactory performance and assessment. This could not be implemented immediately and some element of application and competition may still need to be retained to meet the needs of the service and availability of training places. This should be explored specialty by specialty.[5]


16. In July 2003, less than a year after Unfinished Business, the Department of Health published another consultation paper, Choice and Opportunity. This paper addressed difficulties experienced by the large and diverse group of doctors in Staff grade and Associate Specialist (SAS) posts, a term applied to doctors outside the formal training system and without consultant or GP status.[6] Choice and Opportunity described a number of problems affecting SAS doctors, also known as Non-Consultant Career Grade (NCCG) doctors, including:

  • The lack of a recognised career structure for SAS doctors: the Department commented that these posts "have been regarded as a professional cul de sac";
  • Variation in the type of work done by SAS doctors and the level of training and professional development available;
  • Stigma attached to the SAS grades;[7] and
  • Lack of information about SAS doctors, including total numbers, though the Department estimated that there were around 12,500 SAS doctors in 2003.

17. Choice and Opportunity established principles for reforming the careers of SAS doctors: there should be clear criteria for doctors entering SAS posts to fulfil, as well as the possibility of career progression through the acquisition of recognised competencies. In addition, doctors in SAS posts should have access to training, continuous professional development and careers advice, and SAS posts should be recognised as valid career choices in their own right.[8] The report proposed 14 detailed recommendations for changing SAS posts in line with these principles.[9]


18. Unfinished Business and Choice and Opportunity made a direct case for the reform of the medical workforce, describing specific problems experienced by groups both inside and outside the training system: SHOs and SAS doctors respectively. In addition, there were several other factors and trends, often less explicitly related to medical education, which influenced the design and implementation of MMC:

Turning principles into practice


19. Unfinished Business received widespread support during the consultation process and in February 2003, the four UK health departments published Modernising Medical Careers, a joint initial response to Unfinished Business.[12] The document endorsed both the principles and many of the practical proposals set out in Unfinished Business, including the creation of a two-year Foundation programme. A review of the content and length of specialty training programmes was called for, though it was stressed that this should be done "on a specialty by specialty basis". Modernising Medical Careers also set out plans to review the SAS grades, something underpinned in England by the publication of Choice and Opportunity later in 2003.[13]

20. A UK Strategy Group was formed in October 2003 by Sir Liam Donaldson to co-ordinate and oversee the introduction of the MMC reforms. This was followed in April 2004 by the publication of MMC: The next steps—The future shape of Foundation, Specialist and General Practice Training Programmes. The report set out clear plans for new Foundation Programmes, which it promised to implement from August 2005 onwards.[14]

21. Crucially, The next steps also signalled the intention to adopt "a single, run-through approach" to the delivery of Specialist and GP training programmes. The report explained:

    Specialist Programmes and the General Practice Programme will, therefore, be developed to provide a seamless training process which will see all those emerging from Foundation Programmes entering a training Programme leading directly to the award of a CCT (Certificate of Completion of Training). Entry will be competitive but, subject to satisfactory progress, no further competition will be needed before the completion of training…Special pathways for academics will be designed. We have moved, therefore, from initial proposals which accepted a separation of basic and higher specialist programmes to a system which sees the progressive acquisition of basic and higher specialist competencies in a single programme.[15]

22. The MMC training system, comprising the two-year Foundation programme followed by run-through training, was later set out in the following diagram:

UK MMC Career Framework

Figure 2: Structure of medical training system to be established by MMC

Source: Department of Health Modernising Medical Careers team, November 2005

23. The next steps also set out a simplified set of principles to govern the introduction of the new Programmes. These principles, which became known as the "seven pillars of MMC" established that the new training systems should be:

  • "Trainee-centred;
  • Competency-assessed;
  • Service-based;
  • Quality-assured;
  • Flexible;
  • Coached; and
  • Structured and streamlined."

24. We consider the implications of these principles and what they meant to the different parties involved with MMC in Chapters 5 and 7.


25. The broad aims of the new two-year Foundation Programmes were set out in MMC: The next steps. The first year of the programme (which became known as FY1) would be regulated by the GMC and would bring trainees up to the standards required for full GMC regulation, mirroring the previous PRHO year. The second year (FY2), overseen by the new PMETB, would give candidates a range of practical, communication and decision-making skills.[16]

26. The importance of setting up and evaluating pilot schemes prior to introducing the new programmes was emphasised in Modernising Medical Careers in February 2003.[17] A number of pilots for the Foundation Programme were therefore established: a 2004 survey by the British Medical Association listed a total of 17 pilot schemes; the majority were trials of the FY2 programme and most pilots were carried out in London.[18] Many pilots were not completed and evaluated until after the Foundation Programme had begun in 2005.[19]

27. The curriculum and operational framework for the Foundation Programme were published in June 2005. A total of 23 Foundation Schools were subsequently established across England, bringing together local medical schools, Postgraduate Deaneries and trusts to deliver the new programmes.[20] The introduction of the Foundation Programme was also underpinned by significant financial investment. The first cohort of medical school graduates entered the new Foundation Programmes in August 2005; they would complete the courses in August 2007.


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.


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 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

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