Select Committee on Health Third Report

5  The medical workforce


105. The MMC programme set out to make major structural changes to the UK medical training system through the introduction of the new Foundation training programme followed by the seamless run-through training grade. The implementation of these structural changes coincided with a new approach to selection through the national MTAS recruitment system. MMC was also initially intended to resolve problems affecting the wider medical workforce, including non-training grades.

106. In the wake of the 2007 crisis, there have been widespread calls for many of the changes introduced by MMC to be reversed, or for further changes to be made. The Tooke Inquiry called for significant reform of the structure of training, further changes to recruitment and selection, and for a range of issues outside the training system to be addressed. In this chapter, we look first at the training system, examining debates about the future structure of training and processes for recruitment and selection. We then look at issues affecting the wider workforce, including Staff Grade and Associate Specialist doctors and the consultant grade itself.

The training system

107. The Tooke Inquiry recommended significant changes to the structure of medical training envisaged by MMC. Its proposals, including splitting the two-year Foundation programme and "un-coupling" the run-through grade, were widely supported at consultation.[135] In its response to the Tooke Inquiry, however, the Secretary of State deferred deciding on changes to the training system, calling instead for a "period of stability".[136] In this chapter we examine the case for further change, looking in particular at:

  • The future of the two-year Foundation programme;
  • The specialty training system, particularly in light of the 2007 crisis;
  • The training system for academic medicine; and
  • Processes for recruitment and selection of doctors to the training system.


108. Prior to the introduction of MMC, doctors began their careers by completing a single "pre-registration house officer" (PRHO) year upon graduating from medical school.[137] Following their PRHO year, doctors achieved full GMC registration and could then apply for SHO posts. MMC replaced the PRHO year with the two-year Foundation programme, first implemented in August 2005. The Foundation scheme was to be made up of six four-month placements, including one in General Practice, with GMC registration awarded after the first year.

109. As we have seen, the Tooke Inquiry recommended splitting the Foundation programme and reverting to the training structure which was in place prior to MMC.[138] The inquiry called for a single year of employment upon graduation, followed by GMC registration and then competitive entry into three-year "Core" specialist training programmes. The Department of Health has yet to decide whether to implement this change. In this section we therefore examine the Foundation programme to date and the debate about its future.

Benefits from the Foundation programme

110. Many witnesses, including representatives from the medical profession, praised the new Foundation programme. Postgraduate Deaneries, the organisations with the main responsibility for delivering the new schemes, were particularly positive. The English Postgraduate Deans stated that:

    In general this MMC linked reform has worked well and has adhered to the key MMC principles. It has an explicit curriculum with a well developed, though incomplete, assessment framework. It has been generally welcomed by senior clinicians and trainees alike… The first full 2 year cycle of posts has generally been deemed a success.[139]

111. The Northwest Deanery also deemed the programme "a success", underlining the benefits of exposing more candidates to GP training at an early stage in their career.[140] The London Deanery pointed out that appropriate funding and piloting prior to introduction had helped to ensure that the programme worked well.[141] Peter Rubin from PMETB, the body responsible for regulating the second year of Foundation training, also noted that there was "something of considerable value" in the new schemes.[142]

112. Unsurprisingly, such witnesses opposed the proposal that the Foundation programme be split. Professor Elisabeth Paice, Dean Director for the London Deanery, stated that "in general postgraduate deans are very sad about the proposal to break up the foundation year."[143] Professor Alan Crockard, former National Director for MMC, also supported the continuation of the two-year programme, arguing that it would helped to support "a vitalisation of primary care" by promoting General Practice as a career choice.[144]

113. The BMA also disagreed with the Tooke Inquiry's proposal. Dr Ian Wilson stated that the BMA supported the continuation of the two-year Foundation programme:

    We actually think that of all this period the foundation year appears to have been one of the successes—the two years. I think we disagree that separating the two parts out would be a good thing.[145]

Problems with the Foundation programme

114. Some witnesses, however, cited problems with the new Foundation programme. The Royal College of GPs and Committee of GP Education Directors (COGPED) both pointed out that the goal of providing at least one General Practice placement for all Foundation doctors had not been achieved.[146] The RCGP stated that fewer than 50% of doctors had access to a GP placement during Foundation training:

    Over half of all doctors graduating from the Foundation Programme are denied vital early clinical experience of caring for patients in their usual community based environment. As a result, they are denied the opportunity to see natural history, care pathways, multiple morbidity and chronic disease management.[147]

115. The National Association of Clinical Tutors described other shortcomings in the Foundation programme, including inadequacies with assessment processes and a lack of career guidance for doctors.[148] This problem was also highlighted by the interim report of the Tooke Inquiry, which set out a range of concerns with the Foundation scheme:

    …there are residual concerns about the Foundation Programme. Prominent amongst these are the integration of FY1 with the final undergraduate year, the validity and robustness of the competency assessments, the length of FY2 placements and in many cases their relevance, and the premature choice of specialty half way through FY2.[149]

The need for evaluation

116. Other witnesses argued that it was too early to judge whether the Foundation programme had been an overall success, pointing out that the first cohort of Foundation trainees only completed the scheme in August 2007. Professor Neil Douglas commented on the lack of opportunity to evaluate the programmes:

    …some of us were surprised that the recommendation [in Aspiring to Excellence] to split F1 and F2 was not really compatible with recommendation 2, which is that everything should be evidence based, because the evidence is not in.[150]

117. Dr Bill Reith of the Royal College of GPs made a similar point, arguing that there was not yet enough evidence upon which to assess the Foundation programme.[151] The Department of Health's response to the Tooke Review agreed, citing mixed and incomplete evidence as a justification for deferring its decision on the future of the Foundation programme:

    There have been representations from the organisations responsible for managing the delivery of training that report encouraging feedback from foundation trainees and have requested a full five years of development and evaluation for the current Foundation Programme.[152]

The legal situation

118. The final report of the Tooke Review, however, raised a fresh problem with the Foundation programme by questioning the legality of the current arrangements. Aspiring to Excellence pointed out that UK medical schools must offer their graduates the opportunity to achieve GMC registration. UK graduates, however, cannot in theory be guaranteed a place on the Foundation scheme, making it impossible for universities to discharge this obligation:

    Universities are required under the Medical Act to assure the quality of the FY1 placement and at the end of the year of provisional registration affirm (or otherwise) that the new doctor is suitable for full registration with the GMC. EU medical graduates requiring provisional registration are currently legitimately able to compete for FY1 positions. If that situation is maintained it is only a matter of time before a UK medical graduate is excluded from a FY1 position. This would prevent Universities from fulfilling their obligations to the new graduate.[153]

119. The Tooke Review argued that this situation could only be addressed by splitting the Foundation programme:

    By uncoupling FY1 and FY2 in an employment sense, UK medical students at entry to medical school can be guaranteed an FY1 position. The Panel has been unable to confirm any other legally defensible way in which this situation can be assured.[154]

120. Others, however, questioned the Tooke Review's assertions. David Sowden, former chair of the English Deans and now SRO for MMC at the Department of Health, raised doubts about whether the Tooke Inquiry's recommendations were themselves legally sound:

    From a deanery perspective, there are also particular issues around the proposals on foundation programme training and its linkage to the guarantee of employment for UK graduates. There is some doubt about the legality of that particular statement and therefore we are concerned about it.[155]

121. NHS Employers called for an "urgent review" of the Foundation training arrangements, in light of the questions about their legality.[156] The Department of Health did not comment in its response to the Tooke Review on the specific questions about the legality of the Foundation programme.

Conclusions and Recommendations

122. The implementation of the new two-year Foundation programme did not suffer from the errors which marked that of specialty training. We heard evidence of significant benefits from the new schemes as well as a number of continuing problems. It is too early to judge whether the new Foundation programme has proved an overall success and we therefore recommend that the current two-year scheme is retained while a full evaluation of its impact is carried out in due course.

123. We note the Tooke Inquiry's concern that the current arrangements for the Foundation programme are not legally sound. We recommend that the Department address this question as a matter of urgency and, if necessary, consider introducing legislation to safeguard the legality of the current two-year programme. Only if no lawful alternative can be found should the Tooke Review's recommendation to split the Foundation programme be accepted.


124. The most radical changes attempted by the MMC programme were those made to Specialty training in 2007. MMC set out to replace the previous SHO and Specialist Registrar grades with a single seamless "run-through" training grade, taking doctors from the end of Foundation training through to eligibility for consultant appointments. Run-through training posts, lasting from five to seven years, were offered in all fifty-nine specialty areas from August 2007. A number of one-year Fixed-Term Specialty Training Appointments (FTSTAs) were also offered, in order to create additional capacity during the transition period.

125. Although the new national MTAS recruitment system was largely to blame for the 2007 crisis, the situation was exacerbated by the creation of run-through and FTSTA posts. As a result, the Tooke Review called for run-through posts to be "un-coupled" and for a "Core" specialist training programme to be put in place, followed by a separate "Higher" training scheme. We consider below the problems caused by the 2007 structural changes and the options for future change.

Run-through training

126. Witnesses consistently emphasised that the creation of a single run-through grade, without opportunities for candidates to switch between different run-through schemes, contradicted MMC's aim of increasing flexibility. The excess rigidity of the new arrangements was emphasised by the BMA, the Royal College of Physicians, the Yorkshire Deanery and RemedyUK.[157] These groups pointed out that run-through arrangements forced candidates to make their choice of future career too early, and did not provide adequate opportunities to switch to a different career, or to leave and re-enter the training system. The Royal College of Psychiatrists described the run-through system as "rigid beyond imagination".[158]

127. Further criticism was levelled by the NHS Workforce Review Team, which pointed out that the intention to create competencies that could be transferred from one run-through training scheme to another had not been realised. The Review Team commented that this would make it more difficult to respond to future service needs:

    Despite new competency-based curricula, the system is less flexible as it does not yet have the ability for trainees to take competences, or better capabilities, from one specialty to another. Therefore, there are now 59 separate training systems rather than the original intention of six to eight base specialties, with later ability to specialise as the workforce needs arise.[159]

128. The Department of Health acknowledged that the run-through scheme introduced in 2007 had made the training system more inflexible. It accepted that few doctors were equipped to make long-term career decisions by the end of the Foundation programme and that competencies could not yet be transferred between different run-through schemes. The Department concluded that:

    …the principle of seamless specialist training has been implemented in run-through training programmes that do not currently provide the level of flexibility originally envisaged.[160]

Fixed Term Specialty Training Appointments

129. The creation of one-year FTSTA posts, of which more than 4,000 were offered in 2007, was also consistently criticised. In particular, witnesses pointed out that FTSTA doctors had no guarantee that they could continue their training, making their future career prospects very uncertain. Some predicted that many doctors would end up moving from one FTSTA post to another without being to able to progress to run-through training. NHS Employers described FTSTAs as "a second-rate career path, unpopular and hard to fill".[161] RemedyUK was blunter still, calling FTSTAs "dead-end" jobs.[162] The Royal College of Surgeons warned that:

    Trainees in FTSTAs complete a one year training post and then have to re-apply for run-through training alongside all the other eligible candidates...This creates potential for an exponential growth in the number of trainees competing for run-through posts each year...[163]

130. The Tooke Inquiry, the Royal Colleges of Surgeons and RemedyUK all warned that FTSTAs were at risk of becoming a new "lost tribe".[164] Fidelio vividly described the two-tier system created by the simultaneous introduction of run-though and FTSTA posts:

    In reality, RT has become a cage which keeps those inside safe from preying FTSTAs, but also stops those inside from getting out…[165]

"Core" and "Higher" training

131. In order to address the problems created by the new structures for Specialty training, the Tooke Review recommended "un-coupling" run-through training programmes to create separate "Core" and "Higher" training schemes. Aspiring to Excellence recommended that:

    At the end of FY1 doctors will be selected into one of a small (e.g. 4) number of broad based specialty stems: e.g. medical disciplines, surgical disciplines, family medicine, etc…Core Specialty Training will typically take three years and will evolve with time typically to encompass six six-month positions.[166]

132. The Tooke Review also emphasised that doctors in "Core" training should have the flexibility to leave and re-enter the training system and to switch between different training schemes.[167] Royal Colleges representing a number of major specialties, including Surgery, Radiology and Psychiatry, expressed support for the idea of un-coupling run-through programmes.

The case for a mixed economy

133. Anticipating the Tooke Review's proposals, many specialties un-coupled their run-through training programmes prior to the 2008 recruitment process, offering two or three years of "specialty core training" instead. Core programmes were offered in Medicine, Psychiatry, Anaesthetics and most surgical specialities. Run-through training posts continued to be offered in General Practice, Paediatrics, Obstetrics and a number of smaller specialties. This compromise arrangement was termed a "mixed economy" of training programmes by the Department of Health.[168]

134. The Royal College of Paediatrics and Child Health strongly defended its continued use of run-through training contracts, arguing that this still allowed for considerable flexibility within its specialty area:

    We have always envisaged there would be the possibility to move between specialties and our flexible length of training programme allows this to happen…We believe within paediatrics we have within our allocation to subspecialty training a system that is very sensitive to workforce needs. In this we adjust the numbers entering subspecialty training according to predicted vacancies in the subspecialty that are likely to occur in 2-3 years time.[169]

135. In its response to the Tooke Review, the Department defended the "mixed economy" and asserted that the run-through training model continued to meet the needs of some specialties. The decision on whether to implement the Tooke Review's recommendation for "Core" training across all specialties was therefore deferred:

    …some specialties believe that run-through training will best meet their needs beyond the 'transition period' suggested… This was demonstrated in the DH consultation in September 2007, which gave a broad consensus on the proposals that will be implemented in August 2008 for a 'mixed economy' of training structures… Those specialties which most need flexibility have already started the process of decoupling. Consequently, it seems sensible to evaluate whether the MMC 2008 model of training meets the needs of stakeholders before making further changes.[170]

Conclusions and Recommendations

136. It is clear that the creation of run-through posts across all specialties in 2007 was a serious error. The rigidity of many 2007 run-through schemes contradicted MMC's principles of increasing flexibility and providing a broad-based beginning to specialty training. Run-through training was especially unsuited to the needs of a number of large specialties, include general medicine and surgery. Such specialties have already un-coupled their run-through programmes for 2008 and we support this development.

137. We do not agree, however, with the Tooke Review's recommendation that un-coupling should take place across the board. It is clear that the run-through model has advantages for some specialty areas and may help to attract doctors to traditional shortage specialties. It is also evident that flexibility can be built into run-through schemes, as the case of Paediatrics has demonstrated. Most persuasively, it was the imposition of a "one size fits all" structure which caused such problems in 2007. Forcing all specialties to un-couple would risk repeating this mistake. We therefore recommend that the "mixed economy" of specialist training structures introduced in 2008 be retained and that any future changes be supported and led by the specialties concerned. We further recommend that specialties be permitted to offer a mixture of run-through and un-coupled training posts where this best meets their needs.


The impact of the 2007 reforms

138. The introduction of the MTAS selection system and the new structures for Specialty training in 2007 appears to have had a particularly negative impact on the training system for academic medicine. The Academy of Medical Sciences expressed "grave concern" that the rigidity of run-through training schemes made it very difficult for doctors to pursue academic activities, particularly because of the lack of opportunities to take time out of training in order to conduct research.[171] Fidelio described academic medicine as "an apparently small but vital piece of the jigsaw" which was badly overlooked during the introduction of MMC.[172]

139. The Tooke Review warned that a "binary divide" was being created between the academic and non-academic training systems and pointed out the lack of opportunities for "broader clinical involvement in academic activity".[173] It concluded that:

    …the MTAS selection process diminished the relevance of academic achievement. Such a message coupled with a reluctance to commit to out of programme activity threatens the attractiveness of the clinical academic career. The rigid interpretation of 'run-through' also presents challenges for clinical academia, potentially discouraging would be academics from taking time out of a tightly regulated programme.[174]

140. This conclusion was borne out by Department of Health statistics which showed that only 57% of academic training posts were filled during Round 1 of recruitment in 2007. This was considerably lower than the overall average fill rate (85%), and lower even than the fill rate for FTSTA posts (64%).

Strengthening academic medicine

141. In order to revitalise the academic training system, Fidelio called for more opportunities for doctors to enter and leave clinical training, particular in order to conduct research activities. Fidelio also recommended that the number of academic training posts be expanded to compensate for the training opportunities which were lost when MMC was introduced.[175] The Tooke Inquiry made similar recommendations, urging that:

    Integrated clinical academic training pathways in all specialties including general practice should be flexibly interpreted and transfer to and from conventional clinical training pathways should be facilitated.[176]

142. In its response to Aspiring to Excellence, the Secretary of State expressed support for this recommendation and pledged to provide more effective academic training opportunities in future. The response called for medical schools to become more involved in delivering academic training and stated that:

    The academic clinical training programme will continue to evolve to ensure that supportive career management and mentoring of junior doctors is core to the programme.[177]

Conclusions and Recommendations

143. Academic medicine is a vital part of the training system which appeared to be badly neglected and damaged by the MMC reforms. Research opportunities should be accessible to all doctors in training, while dedicated academic training posts must be made more attractive. To this end, we echo the Tooke Review's recommendations that integrated training schemes be developed and that doctors be allowed to transfer to and from the clinical training system in order to conduct research. We further recommend that the number of centrally funded academic training posts be increased and that the academic training system run parallel to that for mainstream clinical training.


144. We saw in Chapter 3 that the introduction of the national MTAS recruitment system was at the heart of the 2007 crisis. A flawed short-listing system, rushed and inconsistent assessment processes, and the eventual abandonment of the central IT system were among the most prominent failings. We look more closely at how such an inadequate system came to be introduced in Chapter 7; in this section, meanwhile, we look at how the recruitment process itself can be improved.

Centralised or localised recruitment?

145. We have seen that the centralised nature of the MTAS recruitment system caused major problems in 2007. Key aspects of the national system, comprising a central computer portal, a nationally agreed application form and a single national timetable with one starting date per year, were ultimately abandoned for specialty training. Responsibility for arranging interviews and making offers to candidates were devolved to local Deaneries in May 2007. This trend continued when Deaneries were given responsibility for leading the 2008 specialty recruitment process and the Department confirmed that the central IT system would not be used for specialty selection in 2008.[178]

146. Some specialties nevertheless opted to maintain a nationally co-ordinated selection system for 2008. These included Paediatrics, Obstetrics, Public Health and several surgical specialties.[179] A central recruitment process will also be run for General Practice in 2008, following the relative success of a new selection system in 2007.[180] As with the structure of specialty training itself, a "mixed economy" of recruitment systems is therefore operating in 2008. It is notable that several traditional "shortage" specialties have chosen to run a national recruitment system and to continue to offer run-through training posts in 2008. A central recruitment system also continues to operate in support of the Foundation training system.[181]

147. Many witnesses had no objection in principle to the use of centralised systems to support the selection process, but asserted that the specific arrangements for specialty recruitment in 2007 were ill-conceived and prematurely introduced. The Royal College of Paediatrics pointed out the advantages of centralised recruitment for rationalising the workload of assessors.[182] Fidelio, by contrast, opposed the future use of centralised recruitment methods, warning against introducing "a son-of-MTAS that quietly sweeps this year under the carpet."[183]

Staging the recruitment process

148. While different views were expressed about how centralised the recruitment process should be, witnesses consistently opposed another feature of the 2007 system: the introduction of a single date (1 August) for doctors to move to their new jobs. Sir Jonathan Michael emphasised the disadvantages, and potential impact on patient safety, of having only one change-over date per year:

    They are significant because of the implication for service delivery and training. Employers are required to provide mandatory training and induction programmes. If everybody changes on the same day employers will struggle to maintain effective services during the initial few days or couple of weeks.[184]

149. Sir John Tooke agreed, stressing the importance of returning to a staged recruitment process with posts beginning at several points in the year. He also pointed out that this would make it is easier for doctors to leave and re-enter training, describing staged recruitment as "another dimension of flexibility".[185] The Royal College of Surgeons concluded that:

    The flexibility offered by having more than one recruitment round per year would be welcomed both by trainees (because they will have more than one opportunity to compete in a year) and by employers (a staggered start for the new intake of trainees would reduce the impact on the service).[186]

150. The principle of returning to a staged recruitment process was supported by the Department of Health. The arrangements for 2008 recruitment allowed for up to three selection rounds within the year, although the 1 August recruitment round remained the largest.[187] In his response to the Tooke Review, the Secretary of State acknowledged the need to stage the recruitment process, pointing out that this was a stated goal of the MMC Programme Board.[188]

New selection methods

151. Some witnesses advocated the introduction of new methodologies to the selection process, provided that suitable piloting and evaluation were carried out first. The idea of using a national "metric", based perhaps on scores in standardised tests or exams, to support the short-listing process was widely suggested. Professor Elisabeth Paice suggested that this would help to distinguish between large volumes of applicants much more effectively than the "white box" questions widely used in 2007:

    … there should be some kind of test that provides a baseline; otherwise, we cannot cope with volume applications, and we are likely to get them from within Europe if we make our training as good as we would like it to be.[189]

152. The introduction of a new "metric" was strongly supported by Professor Neil Douglas, who stated that this idea had been suggested in 2005, when it was rejected by the Postgraduate Deans.[190] Anne Rainsberry from NHS London was also positive about the proposal.[191] Professor Paice pointed out that a machine-marked test had successfully been used to support the GP recruitment process in 2007.[192]

153. In its response to the Tooke Review, the Department stated that "a programme of recruitment and selection pilots" was currently being undertaken by the MMC Programme Board with a view to introducing some new selection methods. The Department described pilot schemes looking at two new recruitment methods:

    …machine-markable tests: invigilated shortlisting ranking tests that are machine-marked, similar to the CPS test developed for GP training selection…[and] selection centres: a combination of selection methods used together to assess an applicant against defined requirements. [193]

Conclusions and Recommendations

154. The crisis of 2007 was caused in large part by the failure of the recruitment system for specialty training. In response, the Department has handed control of recruitment back to the Postgraduate Deaneries who largely reverted to traditional selection processes in 2008. We support this move and recommend that the Department devolve all responsibility for recruitment to Deaneries as soon as possible, including allowing them to set their own timetables. Deaneries should in turn do more to involve local employers and individual consultants in the design and implementation of selection systems.

155. The delegation of responsibility for recruitment to regional and local organisations should not prevent Deaneries from organising national selection processes when this approach best meets the needs of particular specialties. Nor should it stop Deaneries from using centralised infrastructure, including IT software, where they consider it necessary to improve recruitment and when adequate piloting has taken place.

156. The imposition of a single start date for all training programmes in 2007 was a serious error which reduced the flexibility of the recruitment system and had the potential to compromise patient safety. We recognise that a staged approach to recruitment has been introduced in 2008 and we support this move. We recommend that a staged recruitment process, with at least three substantial recruitment rounds per year, be established in the future.

157. The serious problems experienced in 2007 should not prevent Deaneries from exploring future changes to selection methods. It is vital, however, that such changes are carefully tested and evaluated prior to implementation. We note that the MMC Programme Board has established a pilot programme for new selection methods and we support this approach. In particular, a recognised national test or exam, also referred to as a national "metric", has the potential to increase the objectivity of short-listing and to make recruitment more efficient. We recommend that the Programme Board consider the case for introducing a national "metric" as a matter of priority.

The wider medical workforce

158. We saw in Chapter 2 that part of the rationale for the MMC programme was the Choice and Opportunity paper, which highlighted the problems experienced by doctors outside the formal medical training system. Its very title, focussed on "careers" rather than on "training", implied that MMC would seek to address some of these wider workforce issues. In practice, however, the initial reforms focussed largely on changes to the structure and content of training. This focus further intensified in the wake of the 2007 crisis and the Tooke Inquiry, whose remit related mainly to the training system. In this section, we move away from the training system and examine MMC's impact on the wider medical workforce. We look in particular at:


Changes to date

159. The problems affecting Staff Grade and Associate Specialist (SAS) doctors were articulated in Choice and Opportunity which criticised the absence of a recognised career structure and the lack of formal training available for SAS doctors, as well as the stigma attached to SAS posts. It recommended both that SAS doctors be allowed to acquire formal competencies to help with career progression and that more consistent training and careers advice to be provided.[195]

160. Witnesses argued that some progress had been made in improving the SAS grades since 2003. Dr Moira Livingston, who previously worked at the Department of Health to implement Choice and Opportunity, described the achievements to date:

    …there are some things that we did manage to achieve. One was to bring together a body of evidence for the employer to understand how to ensure that doctors in these roles could fully reach their potential…and how employers could view them differently in terms of their contribution as clinical leaders within organisations, so their role as managers, teachers, their role in research.[196]

161. Meanwhile PMETB pointed out that the introduction of a separate route to achieving specialist registration, by-passing the formal training system, had improved prospects for SAS doctors. The Certificate of Eligibility for Specialist Registration (CESR), established in 2005, was praised by PMETB:

    Doctors who have not completed a full training programme can seek to demonstrate to the Board that they have the same level of skills and knowledge as a doctor who has successfully completed a specialist training course leading to the award of Certificate of Completion of Training (CCT). If their application is successful then they will be entered on to the specialist register and be eligible to compete for consultant posts within the NHS.[197]

Limitations of progress

162. Despite these changes, however, the Committee heard that overall progress on the reform of SAS posts had been distinctly limited. Most importantly, Dr Moira Livingston argued that the MMC programme had failed, and continued to fail, to prioritise the reform of the SAS grades:

    the reaffirmation of the principles of the MMC Programme Board [in 2007], which were deemed MMC principles, actually are MMT principles and actually modernising medical training principles because they do not take account of Choice and Opportunity, which was a key part of the whole programme…[198]

163. Dr Livingston also acknowledged specific limitations to progress. She stated that the development of transferable competencies and a "credentialing" system for SAS doctors, which would allow experience gained in SAS posts to be recognised alongside formal training, had not yet been achieved. The absence of a "credentialing" system has limited the impact of the development of the new CESR route, as there is no clear system whereby SAS doctors can demonstrate that they meet the CESR requirements. Dr Livingston stated that:

    Where we were unable to gain any momentum was around the issue of credentialing. The origin aspiration had been that doctors in the new career post would be able to get the credentialing as they progressed within their job learning as they go for new competences that they have gained, and there just is not a regulatory structure in place to support that…. [199]

164. Dr Livingston pointed out that the planned implementation of a new contract for SAS doctors had been delayed, preventing other changes from being introduced:

    …there has been a delay in that we felt that the new contact was an essential component of Choice and Opportunity, and whilst waiting for that to be agreed there has been a hold on the publication of the work that we did within the MMC team...[200]

165. The Tooke Inquiry also argued that the failure to agree the new SAS contract had hampered progress. It stated that the SAS grade would continued to be regarded as "a diversion into a cul de sac" if further changes were not made.[201] Aspiring to Excellence made recommendations which echoed many of those put forward in Choice and Opportunity four years earlier:

    Staff grade positions must be destigmatised and contract negotiations rapidly concluded…Doctors in these posts should have access to training overseen by Postgraduate Deaneries and CPD opportunities. They should be able to make a reasonable limited number of applications to Higher Specialist Training positions according to the normal mechanisms. The capacity to achieve CESR through the Article 14 route and CEGP through Article II should be retained.[202]

The new SAS contract

166. Sian Thomas of NHS Employers told the Committee that the new contract for SAS doctors had been agreed in principle by the BMA and the Department of Health in November 2006. She pointed out, however, that the Government did not ratify the contract until more than a year later in December 2007.[203] In March 2008, 60% of SAS doctors voted to accept the new contract with effect from April 2008.[204]

167. The Secretary of State acknowledged that ratifying the contract had taken longer than expected, blaming this problem on wider restrictions on public sector pay increases.[205] He argued, however, that the new contract would bring significant benefits for SAS doctors:

    I am not suggesting that everything now is coming up smelling of Chanel for this particular group but I do say that we have paid some attention to their concerns and sought to get a fair deal with their representatives which means that they are not forgotten or left out of the huge changes and improvements that have gone on in the NHS over the last ten years.[206]

Linking SAS posts to the training system

168. Witnesses emphasised that the ultimate aim of the new contract and other changes to the SAS grade should be to develop such roles into an effective supplement or alternative to the formal training system. The Tooke Inquiry argued that SAS posts should become a "parallel alternative career route".[207] Aspiring to Excellence pointed out the potential benefits to training doctors of working in SAS posts:

    The advantages of the grade (accrual of experience in chosen area of practice, consistent team environment) need to be made clear. [208]

169. Dr Moira Livingston made a similar point, arguing that the creation of a viable alternative to the specialty training system would strengthen the medical workforce and make reform of the training system less controversial.[209] The English Postgraduate Deans agreed, but argued that progress on achieving this had been limited:

    …some trainees need an alternative career structure within Medicine to that offered by the route to CCT or CESR/CEGPR…The Staff and Associate specialist (SAS) grade offers a potential alternative route but the present impasse over the SAS contract is having a very negative effect on junior doctor's perception of this grade. Choice and Opportunity offered a mechanism to explore the educational infra-structure to support this grade but this remains largely unexplored.[210]

170. As we have seen, Dr Livingston stated that little progress had been made on such infrastructure developments, such as the introduction of transferable competencies for SAS doctors. She told the Committee that changes of this type would help to develop the SAS grade as an alternative to training but had been prevented by the lack of clarity regarding regulatory responsibility for SAS doctors:

    Because the doctors in the career posts are not part of the training structure…they fell outwith the remit of PMETB and, although we did work with Skills for Health to look at a structured framework for their development, again it was something that could not sit with the GMC in its remit and could not sit with PMETB.[211]

Conclusions and Recommendations

171. Reforming the Staff Grade and Associate Specialist (SAS) grades was one of the original aspirations of the MMC programme. To this end, the establishment of a new way of achieving specialist registration, the CESR route, is a welcome development. Wider progress, however, has been limited and access to training and CPD remains patchy. In particular, the failure to implement a "credentialing" system has prevented training and experience gained by SAS doctors from being formally recognised, meaning that SAS posts continue to be regarded as inferior to traditional training posts. The introduction of a new contract for SAS doctors has also been delayed, further hampering progress. We recommend that the introduction of this new contract be given a high priority by the Department.

172. The failure to substantially reform the SAS grade is highly disappointing, in particular because SAS posts have the potential to provide an attractive alternative to the formal training system. This potential must be realised in the future. Such a development would not only belatedly improve prospects for SAS doctors themselves, but would also reduce pressure on the traditional training system. In order to achieve this, we recommend that:

  • The remit of the MMC Programme Board be widened to include reform of the SAS grade;
  • Responsibility for regulating the training received by SAS doctors be given to PMETB, and subsequently to the GMC;
  • The regulator work with the relevant Royal Colleges to develop a "credentialing" system to allow experience and competence gained in SAS posts to be recognised alongside formal training and to make it easier to achieve specialist registration via the CESR route; and
  • Employers make use of the new SAS contract to ensure consistent access to and funding for training and development and to develop extended roles for SAS doctors.

173. These changes would ensure that the SAS grades become a recognised part of the training system, providing a genuine alternative to traditional training posts and giving doctors the opportunity to develop specific skills to a very high standard. This would significantly increase the overall flexibility of the training system and greatly reduce the need for temporary FTSTA posts. It would also ensure that the UK no longer has a two-tier medical workforce and that in future all doctors are either in training or fully trained.


174. The principal aim of the specialty training system is to produce doctors suitable for appointment as consultants. Witnesses stressed that changes to the training system and the SAS grade would in turn create a need for changes to the consultant grade. Others called for reform of the consultant grade in response to wider changes to the medical workforce and the health system.

Differentiation within the consultant grade

175. Sir John Tooke explained to the Committee how the role of the consultant has changed in recent years, arguing that the breadth of responsibilities covered by individual consultants had decreased:

176. He went on to argue that this change had created a need for increasing differentiation, and the development of distinct levels of seniority, within the consultant grade:

    It is likely that there will need to be some differentiation at the top end of the profession. It seems unlikely to me that you can have the majority workforce made up of autonomous practitioners operating in precisely the same role…A useful analogy that has been put forward is that in clinical academia you recognise at consultant level that you can have a senior lecturer, reader and a professor. Therefore, there is a differentiation within that hierarchy.[213]

177. Some witnesses felt that the best way to address this issue would be to create a separate grade below the current consultant grade. Professor Stephen O'Rahilly proposed that a "sub-consultant or specialist grade" be created for doctors to enter immediately upon completing training.[214]

178. Representatives of the BMA agreed on the need for differentiation within the consultant grade, but did not feel that the creation of a separate "sub-consultant" grade would be the best way to achieve this. Dr Ian Wilson argued instead that senior consultant posts should be created to offer the possibility of progression within the grade:

    What we believe …is rather than creating a second grade which actually achieves nothing and delivers nothing and has no place that cannot be dealt with in existing structures is to create a portfolio within the consultant grade.[215]

179. Mr Bernard Ribeiro agreed, pointing out that at present most consultants remain in much the same job role for the whole of their working life. Like the BMA, he argued that differentiation would best be achieved by introducing senior positions above the existing consultant level:

    We are more inclined… to look at how we can take the established consultant body and look at means of progression, not take the view that a consultant appointed at 35 will practise in the same way throughout the whole of his career. He will have to demonstrate why that progression should occur. That might well give some structure to the consultant level.[216]

Consultant-led or consultant-delivered care?

180. Witnesses also emphasised the importance of deciding what proportion of care which should be provided by consultants. It was stressed that if the NHS were to move from a primarily consultant-led to a primarily consultant-delivered service then this would significantly reduce the amount of care delivered by doctors in training.[217] It would also affect the overall number of consultants and training doctors required by the NHS. A consultant-led service would also increase the ratio of consultants to doctors in training, increasing the number of consultants available to teach and supervise.

181. The Royal College of Surgeons argued that the 2000 NHS Plan had envisaged the creation of a consultant-delivered NHS. However, it warned that this commitment was now in doubt:

    The unprecedented growth in the medical workforce offers a remarkable opportunity for the NHS to be a consultant-delivered service. This was aspired to in the 2000 NHS Plan and has the full support of the medical profession. Despite this, the uncertainty created by current NHS reforms and the focus on fiscal matters has jeopardised the chance to achieve a consultant delivered NHS…There needs to be agreement and clarity from the Department of Health…as to whether the NHS should be a consultant-delivered service or a consultant-led service.[218]

182. When questioned by the Committee in 2007, David Nicholson, NHS Chief Executive, stated that the issue of whether to move towards consultant-delivered care was still being considered by the Department of Health:

    There are some really important issues here that have not finally been teased out. The most obvious one is what is the nature of the service that we are going to be taking forward in the future? Is it going to be a consultant-led service or a consultant-delivered service? That has a big impact in terms of the numbers of staff that you want. We have not come to a conclusion on all of that…[219]

183. The Secretary of State denied that the Department's policy had changed since 2000, commenting cryptically that care would be "clinician-led and locally driven" in the future.[220] He subsequently stated that the specific question of whether to offer consultant-led or consultant-delivered care would be considered by the NHS Next Stage Review.[221]

Conclusions and Recommendations

184. The changes introduced by MMC also have significant implications for the consultant workforce. Shorter overall training times and increasing sub-specialisation both point to a need for greater differentiation within the consultant grade. We recommend that the Department of Health and the relevant medical Royal Colleges examine the introduction of a hierarchy within the consultant grade similar to that used in clinical academia.

185. We were surprised that the Secretary of State was not able to say whether he remains committed to the NHS Plan aspiration of moving from consultant-led to consultant-delivered care in the NHS. This is a critical question with fundamental implications for the size and nature of the consultant workforce, and for the role of the training system. We recommend the Department resolve this issue conclusively as part of the NHS Next Stage Review. The Department must recognise that moving away from its commitment to consultant-delivered care would have significant implications, potentially throwing medical workforce planning into still more confusion and further damaging relations with the medical profession. This decision should not be taken lightly.

186. We are also concerned by the apparent absence of any systematic basis for calculating postgraduate training numbers, something which should have been established as part of the MMC reforms. It is unclear whether the number of training posts is determined by the number of doctors seeking training, by the current capacity for training in the NHS, by the future clinical needs of the health service, or by some combination of these factors. We agree with Professor Tooke that "workforce policy objectives must be integrated with training and service objectives". We recommend that the Department of Health, other relevant Government departments and the medical profession work together to establish and publish and regularly update a clear rationale for deciding future training numbers.

135   Aspiring to Excellence, pp.118-136. See Chapter 3 for more details Back

136   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, pp.47-49 Back

137   It is notable that the traditional PRHO year generally gave new graduates experience only of general medicine and general surgery and that it did not have a formal curriculum Back

138   The inquiry's interim report, published in October 2007, criticised the lack of relevance of some Foundation placements and inadequate assessment processes for trainees Back

139   Ev 74 Back

140   Ev 87 Back

141   Ev 121 Back

142   See Q 660. Professor Rubin is head of the Education Committee of the GMC as well as being chair of PMETB Back

143   Q 602 Back

144   Q 305 Back

145   Q 413 Back

146   See Ev 130 and Ev 185 Back

147   Ev 185 Back

148   See Ev 100-101 Back

149   Aspiring to Excellence, p.43 Back

150   Q 659 Back

151   Q 534 Back

152   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, p.48 Back

153   Aspiring to Excellence, p.46 Back

154   Ibid Back

155   Q 602 Back

156   Q 729 Back

157   See Ev 133, Ev 154, Ev 71 and Ev 140 respectively Back

158   Ev 164 Back

159   Ev 66 Back

160   Ev 10 Back

161   Ev 172 Back

162   Ev 142 Back

163   Ev 114 Back

164   See Aspiring to Excellence, p.88, Ev 114 and Ev 142 respectively Back

165   Ev 190 Back

166   Aspiring to Excellence, p.53 Back

167   See Aspiring to Excellence, p.146. The Inquiry stated that some specialties should be continue to offer run-through contracts for a limited period, but only during the transition to the new system. Back

168   For full details, see GUIDANCE FROM THE DEPARTMENT OF HEALTH TO SHAs ON MANAGING LOCAL RECRUITMENT TO SPECIALTY TRAINING IN 2008, 23 January 2008, p.3. It is notable that while there was a mixed economy between different specialties in 2008, there was no mixed economy within specialties. Back

169   Ev 111 Back

170   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, p.48 Back

171   Ev 54 Back

172   Ev 192 Back

173   Aspiring to Excellence, p.58 Back

174   Aspiring to Excellence, p.68 Back

175   Ev 192 Back

176   Aspiring to Excellence, p.147 Back

177   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, p.51 Back

178   Department of Health press release, LOCALLY LED, STAGGERED RECRUITMENT FOR SPECIALTY TRAINING IN 2008, October 2007 Back

179   These include Cardiothoracic Surgery, Plastic Surgery and Neurosurgery Back

180   See for further details Back

181   Q 477 Back

182   Ev 108 Back

183   Ev 189 Back

184   Q 180 Back

185   Q 181 Back

186   Ev 114 Back

187   Department of Health press release, LOCALLY LED, STAGGERED RECRUITMENT FOR SPECIALTY TRAINING IN 2008, October 2007 Back

188   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, p.51 Back

189   Q 589 Back

190   Q 669 Back

191   Q 740 Back

192   Q 561 Back

193   Department of Health, The Secretary of State for Health's Response to Aspiring for Excellence, p.21 Back

194   Staff Grade and Associate Specialist doctors are described in more detail in Chapter 2 Back

195   Department of Health, Choice and Opportunity, pp.1-4. See Chapter 1 for more details Back

196   Q 752 Back

197   Ev 105 Back

198   Q 752 Back

199   Q 752 Back

200   Q 752 Back

201   Aspiring to Excellence, p.47 Back

202   Aspiring to Excellence, p.146 Back

203   Q 755 Back

204   BMA Press Release, SAS Contract Vote, 17 March 2008 Back

205   Q 941 Back

206   See Q 939. Officials stated (Q 938) that the new contract would offer 10% pay increases of 10% for Staff Grade and 4% for Associate Specialist doctors Back

207   Aspiring to Excellence, p.47 Back

208   Aspiring to Excellence, p.146 Back

209   Q 752 Back

210   Ev 76 Back

211   Q 752 Back

212   Q 197 Back

213   Ibid Back

214   Q 217 Back

215   Q 416 Back

216   Q 543 Back

217   "Consultant-led" care would traditionally be provided by a team of junior doctors, including doctors in training, working under a single consultant. "Consultant-delivered" care would be provided directly by consultants themselves. Back

218   Ev 115 Back

219   Public Expenditure Questionnaire 2006-07, Q54 Back

220   Public Expenditure Questionnaire 2006-07, Q258 Back

221   Q 947 Back

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