Memorandum by Professor Dame Carol Black
(MMC 56)
MODERNISING MEDICAL CAREERS
INTRODUCTION
I have the advantage of having studied Aspiring
to Excellence, Sir John Tooke's interim report of the Independent
Inquiry into Modernising Medical Careers, together with records
of the proceedings of the Health Committee, and familiarity with
developments in MMC following the events last year that led to
this inquiry.
The interim report identifies eight major issues
and proposes actions necessary to correct each of them. I am in
agreement with the conclusions and the corrective actions and
with the broad intention of the recommendations.
This short memorandum focuses on an understanding
of the essential principles on which postgraduate medical education
and training are based. It is ordered to match the focal points
of the Committee's Inquiry.
To what extent the practical implementation of
MMC has been consistent with the programme's underlying principles
1. As the Committee has learnt, the principles
that we believed underlay MMC were defined by the Chief Medical
Officer's Report Unfinished Business. The chief principles
to be observed in postgraduate medical education were that it
should have broad-based beginnings, offer flexibility and be conducted
within a structured programme.
2. Unfinished Business described
flexibility as the ability to support and accommodate varying
needs of trainees and to respond to changing and challenging service
demands. It meant allowing for individually tailored or personal
programmes, with arrangements to facilitate movement into and
out of training and between training programmes. It recognised
that for many doctors, though not all, career decisions could
change during the early years of specialist training.
3. Approaches to training in the past produced
doctors with deep and varied experience and was inherently flexible.
But often it was incomplete. Numbers of junior doctors were trained
through planned rotations of high quality, but for many more,
probably most, training was less well structured and often those
doctors were less well advised and supported than they should
have been. Their training experience was patchy and uncertain,
though they often had much clinical experience and indeed were
vital to the service.
4. With the ever-increasing complexity of
medicine and the need to ensure no significant aspects are overlooked
in training, a more structured approach is necessary today. So
among the profession's purposes in supporting modernisation of
medical careers was to ensure the provision of better-structured
training for every doctor than had been available hitherto.
5. There was a further imperative. It was
to ensure there would never again be a group of doctors, "a
lost tribe", with few further or, at best, uncertain career
opportunities. Indeed if the "lost tribe" were simply
replaced by another it would be seen as a new betrayal. To our
shame, that is just what is happening today.
6. The precise policy aims of MMC, the name
given to the Department of Health programme of training arrangements,
have become obscure. Founding principles have been lost sight
of, and there has been a palpable change in emphasis. The structured
approach remains but it has become rigid, the arrangements allowing
none of the flexibility, including the individual tailoring, that
was promised. There has been a failure to observe fundamental
principles that had earlier received such strong support. MMC
is not really synonymous with training activities centred on curricula,
educational programmes and assessment. It has more to do with
central delivery of training programmes that are closely tied
to the role of junior doctors in delivering service needs. The
weakened focus on needs of trainees themselves became rather clear
during the recent debacle.
7. The potential benefits of broad-based,
themed training are on the one hand a fuller opportunity for making
a mature career choice, and on the other a cadre of doctors whose
sound core specialist training provides the surest foundations
for subsequent specialised differentiation according to service
need and technological and therapeutic progress.
8. A word about specialisation. I can think
of no specialty that works in isolation. The interdependency of
people in different specialties has long been a feature of secondary
care. Now it is reaching seamlessly across and within both primary
and secondary care. It is sensible to recognise this in training
programmes.
9. Sir John Tooke's interim report addressed
the concern to restore flexibility by provision of a period of
core training with diverse experiences, with the opportunity for
individuals to reflect what their choice of subsequent specialist
course should be. That said, for some doctors in particular specialties
a run-through training programme might be more appropriate. Even
then there is a potential loss; for example, removing the possibility
of diversion to explore an unexpected research challenge.
10. The 45 recommendations of Sir John Tooke's
interim report embrace and reflect the original principles and
the means for ensuring they are observed. They captured 87% agreement
or strong agreement across the 45 recommendations. I believe that
is a powerful affirmation of the soundness of the principles espoused
in 2002.
11. Flexibility has come have another meaning,
which has less to do with the sense of enabling doctors to shape
their training pathway in ways that allow them to make adjustments
according to their aptitudes, their early experience of different
fields of medicine and their developing interests. Instead, MMC
described itself as "a key enabler for other DH programmes".
It focused on the development of a flexible workforce of doctors;
but in reality the approach it favoured denied the very flexibility
or adaptability necessary in an evolving service.
12. MMC also stated that the skills and
the absolute guarantee of standards from new methods of assessment
are key to the success of modern workforce programmes like the
Hospital at Night, and the Working Time Directive; and that most
importantly it will deliver a modern training scheme and career
structure that will allow clinical professionals to support real
patient choice. Thus there was a shift of emphasis towards current
service imperatives.
13. It is obvious that training and service
are intertwined, that the experience of service is, and must be,
part of learning; but we must ensure that service is not at the
cost of learning. It is crucial that the long-term investment
in training, including those who have training roles, is not put
at risk by unbalanced pressures to meet service or financial needs
and that secure arrangements are in place to ensure that is so.
14. There was a declaration that "streamlined
training and explicit standards of assessed competence are also
essential if doctors' careers are to accommodate the pressures
of a family and modern lifestyles. MMC aims to greatly improve
the opportunities for those who wish to take a break in their
careers and will promote fairness and equality of opportunity
at all stages of a doctor's career". Such statements ring
hollow today.
15. The experience of MTAS has made the
primary claim open to question. Many believe that MMC appears
to have been designed with the primary purpose of meeting NHS
workforce needs linked to training opportunities. But it has become
clear that for many doctors those opportunities have become seriously
limited. Moreover the arrangements have shown little if any regard
to the career and personal aspirations of trainee doctors.
The strengths and weaknesses of the MTAS process
16. Any process of selection must assess
what is valid, must not ignore what is significant, measure what
it claims to measure, and be capable of discerning between candidates
fairly. It should be accepted by participants—candidates
and assessors, and the public—that the process meets such
criteria. There were demands that the MTAS process be so validated
and evaluated before general introduction, but this was not done.
17. In the selection methodology we find
a shift in the meaning of terms: in the terms competent and competency,
for example. There was an untested belief that the methods of
assessment were capable of recognising and discerning between
the different qualities and attributes that doctors, at each level
of responsibility, must bring to their practice.
18. The approach to competency adopted by
the Department of Health has become reductionist in nature. In
trying to reduce specialist knowledge and skills to a "list
of parts", it loses the sense of how a doctor—like
other professionals who must take important decisions in the face
of incomplete information and uncertainty—is shaped through
education and experience to make the kinds of judgements that
are the essence of maturing practice. It goes without saying that
that they must be competent in the range of functions that are
necessary for safe practice as they undertake training in service.
But the demonstration of a range of competences alone is far from
sufficient assurance of the knowledge, skills and attributes demanded
by the service element that is an indivisible part of training.
Indeed much emphasis was given to requirement that doctors should
be "judgement safe" early in training, particularly
given their part in acute work.
19. May I recall the statement made by Sir
John Tooke in his evidence to the Committee:
"To be proficient and capable in one's role
requires considerable experience, depth of knowledge about one's
discipline, experience in exhibiting fine judgment—a lot
of medicine requires that—and not just a capacity to undertake
certain tasks under defined conditions. I think the idea of proficiency
is a more embracing one that wraps up competence but accepts the
need to embrace these other qualities that we and society would
wish to see in a doctor". It is view with which I wholly
concur.
20. Whatever kind of medicine—I use
the term generically—doctors come to practice, they build
upon common educational foundations. Indeed the soundness of these
foundations is critical to each specialty, from general practice
to the most specialised and arcane sub-specialty. This commonality
permeates the professional ethos; it is recognised and highly
valued by patients; it is very important.
21. The subject of selection and assessment
procedures is treated authoritatively at Appendix 4 of the interim
report.
What lessons about project management should the
Department of Health learn from the failings in the implementation
of MMC
22. The interim report contains a great
deal about the management of MMC, including a detailed forensic
analysis of its proceedings, and I am not in position to add more.
23. Out this analysis emerges a clear need
for a greatly strengthened mechanism for bringing together the
diverse interdependent perspectives that bear on health policy,
workforce requirements and postgraduate medical education and
training, with high accountability.
The extent to which MMC has taken account of the
supply and demand of junior doctors and the number of international
medical graduates eligible for training in the UK
24. The policy decided in 1997 to achieve
medical self-sufficiency in the UK was made a reality by the expansion
of medical schools. From the outset this investment had clear
quantifiable implications for training and the provision of training
posts for all doctors who achieve the required standard. And it
had implications for the future immigration of medical graduates
from outside the EEA, in relation both to postgraduate training
and to employment in the NHS.
25. It is regrettable that failure to address
the issues adequately and in good time has led to the calamitous
position of many doctors in the UK today, not only of UK medical
graduates but also international medical graduates who trained
outside the EEA, including those who have already served the NHS.
The resulting uncertainties facing many able young doctors today
and in the near future call for the swiftest and fairest possible
resolution.
26. The rigid training structure of MMC
has brought other restrictions. The UK has a high international
reputation for postgraduate medical education, fostered particularly
through the links established by the Royal Colleges. It uses that
standing to benefit countries with less developed training programmes.
These links have long supported and enabled education and training,
research, and quality improvement and they facilitate international
exchanges. Appropriate overseas experience for young doctors during
and at the end of training provides important mutual benefits.
27. We should also have proper regard to
the reasonable expectations and claims of doctors from abroad,
the contributions they make to medicine and the service in the
UK, and the skills many are able to take back to their own countries.
The roles of the Department of Health, Strategic
Health Authorities, the Deaneries, the Royal Colleges and the
Postgraduate Medical Education and Training Board in designing
and implementing MMC
28. The roles and responsibilities of these
bodies are intimately related, in respect of service needs, evolving
service opportunities to exploit medical advances, trained workforce
requirements and finance. Yet the linkages between them are often
tenuous and fragile, and sadly, distrustful. I believe we could
and should take steps to expand our alliances and relationships,
to address these matters in new more open collaborative fora.
29. Experience of the development and implementation
of Modernising Medical Careers has brought important lessons for
us all—for the Department of Health, its internal structures,
its relationships and its accountabilities internally and externally;
for the professional institutions, collectively. The interim report
has spelt them out clearly.
30. The experience has also reinforced the
importance of strong medical leadership, its role in developing
and presenting a coherent view of the principles and values that
identify the profession, and the ways in which these must be grasped
and handled in policy development and implementation. Leadership
is a hallmark of professionalism. To warrant that hallmark it
is quite clear that the institutions of medicine, in partnership
with other stakeholders, must construct more effective mechanisms
for safeguarding and advancing the principles they share.
January 2008
| 
