Select Committee on Health Written Evidence

Memorandum by the Conference of Postgraduate Medical Deans (COPMeD) (MMC 57)


1.   Introduction

  1.1  COPMeD provides a forum in which Postgraduate Deans from the four nations meet to discuss current issues, share best practice and agree a consistent and equitable approach to postgraduate medical training in all deaneries across the UK. It acts as a focal point for contact between the Postgraduate Medical Deans and other organisations, eg the Academy of Medical Royal Colleges, Medical Schools Council, GMC, BMA, PMETB and Health Departments for postgraduate medical and dental education matters.

  1.2  COPMeD is not an executive body, but it facilitates the deans taking corporate action. For example, in the last decade the postgraduate deans have successfully implemented wide-ranging reforms of pre-registration and specialist registrar training across the UK. The Committee of GP Education Directors (COGPED) developed and delivered a selection process for GP training over the past seven years administered through an online system in 2006.

2.   Key Points: Executive Summary

  2.1  COPMeD had significant input into the development of the principles of MMC and considers them to be sound.

  2.2  Implementation of Foundation Programmes was assisted by piloting, funding for a new infrastructure, and the fact that there were enough posts for all eligible applicants. The reforms to specialty training were implemented without these features.

  2.3  Transition to the new MMC specialty training structure, in one step, required an unprecedented number of trainees to be recruited at one time. National electronic recruitment was intended to reduce the workload on consultants and deaneries, and hence the cost and service impact. In order to do this effectively, there needed to be a reliable means of ranking applicants electronically.

  2.4  COPMeD supported the introduction of a national computer-marked test which all applicants would take if they wished to apply for specialty training, but other stakeholders—particularly trainee representatives—did not agree. Without this, or any other reliable metric to use for shortlisting purposes, the potential for an electronic process to cut down the workload for consultants was severely restricted. An invigilated computer-marked test was introduced in GP selection and proved an effective way of sifting out less able applicants.

  National electronic recruitment processes are the way forward and should be re-introduced once structural reforms are in place, processes are bedded down, technology has been tested, and there is a reliable metric that can be used to sift applicants at the shortlisting phase and thereafter. As Sir John Tooke has recommended in his interim report, a national computer-adaptive test, to be taken by all applicants, should be developed without delay and piloted for this purpose.

  2.5  Problems with MTAS have drawn attention away from the principles of MMC. There remains a continuing need to reform specialty training, so as to ensure an adequate supply of well-trained doctors competent to provide a modern, safe, high quality service to patients.

  2.6  Failure to manage medical migration has brought into question the policy decision for the UK to become self-sufficient in the production of doctors. COPMeD believes these policies were well-founded and should not lightly be abandoned.

3.   Background

  3.1  COPMeD fully supported the MMC principles. Postgraduate deans and GP directors were engaged in all stages of planning this reform.

  3.2  The senior house officer (SHO) grade was sandwiched between two reformed grades, and increasingly depended upon by the service to deliver front-line care out of hours. The grade burgeoned when controls on the numbers were lifted to help hospitals deliver the 58 hour week (European Working Time Directive- 2004), and at the same time there was an uncontrolled expansion of non-training grade "trust doctor" posts. This expansion resulted in an influx of international medical graduates (IMGs) who came in expectation of entering higher specialist training at a later date.

  3.3  While the Specialist registrar (SpR) grade also expanded this was not sufficient to accommodate all these SHOs and trust doctors, many of whom were employed in surgical specialties, where the demand for consultants is falling. Many doctors, at this level, either tried to progress in specialty after specialty or "queued" ie followed an increasingly demanding (but clearly understood) pathway to enter the specialty of their choice. The latter was typical in some of the surgical specialties, where it commonly took eight or nine years, from leaving medical school, to getting onto an SpR programme. Not all those who queued were ultimately successful, most of the remainder going into staff grade posts or leaving the country.

  3.4  COPMeD opposed the introduction of a run through grade when it was first proposed by the BMA in 1998. Postgraduate deans felt it would force trainees to make their career decisions too early, and the workforce planning horizons would be too long. Improvement of the quality of training could be achieved in other ways. However, as time went on it became clear that the SHO/trust doctor grade was burgeoning, more IMGs were registering with the GMC each year than UK graduates, and fresh UK graduates were having difficulty competing with experienced IMGs for SHO training programmes. Something radical had to be done. The policy statement by the four CMOs, in response to the consultation on Unfinished Business, provided the blueprint.

  3.5  The first step was to provide UK graduates with a firmer foundation from which to compete, and give them more exposure to different specialties, as well as career management support, to help them make their career decisions earlier. Following extensive piloting, the two-year Foundation programme was successfully introduced. Programmes were forged out of the previous pre-registration house officer year and posts that had hitherto been first year SHO posts, supplemented by a significant new investment in GP, academic and shortage specialty placements. An education management infrastructure for each Foundation School was fully funded. Formal evaluations of every aspect of the Foundation Programmes have been positive. COPMeD was disappointed that this evidence was not taken into account in the Tooke report, and would wish to see Foundation Programmes continue, at least until they have been fully evaluated.

  3.6  COPMeD considered it important that the first full cohort of trainees to exit Foundation programme training should move into a modernised specialty training system.

  3.7  The next tasks for postgraduate deans were:

    a)  to deconstruct existing SHO rotations and use the posts to build the early years of specialty training;

    b)  to increase training posts where appropriate by converting trust doctor posts into educationally approved ST1-4 posts; and

    c)  to select trainees into each of four levels of entry to fill the posts.

  3.8  There was concern about whether there were sufficient numbers to accommodate all existing trainees. It was estimated that there were 17,500 SHOs in approved posts in the UK in 2006 (data from PMETB). The census in England in 2005 had identified 21,000 doctors employed at "SHO level", ie including Trust doctors. The number of specialty training posts available across the UK to accommodate these doctors was estimated at 22,000, once 1,000 trust doctor posts had been converted to training posts. These figures indicated more than sufficient posts for all those in the F2 and SHO training grades.

  3.9  COPMeD was aware that there would be applicants from outwith the existing F2 and SHO grades eg Trust doctors; trainees who were engaged in research; those working abroad or taking time out eg for maternity. These were hard to quantify, but we were keen to ensure as many as possible could be accommodated.

  3.10  The other factor that was hard to quantify was the number of applications that would come from European and international medical graduates. If interest was high, experience had shown that some UK graduates would be displaced, especially at the more junior levels of entry.

  3.11  COPMeD strongly supported better management of medical migration. The health service depended too much on IMGs to provide a migrant SHO-level workforce, filling locum and trust doctor posts. This seemed a poor way of providing a service and treating these doctors. Increasingly, trusts were offering IMGs "honorary" SHO posts in which they provided a service in return for training and a foothold in the system. These "posts" did not show up on the census, being unpaid, but they were storing up a further cohort of UK-based doctors with expectations of entering specialty training programmes in due course, and well-placed to compete.

  3.12  COPMeD recognised the reasons for the withdrawal of permit-free training in March 2006, and alerted the DH to the subsequent sharp rise in applicants on the highly-skilled migrant programmes (HSMP). The bar for entry to this programme was low, especially for medical graduates who unlike professionals in other fields achieved the required HSMP entry score without having completed the majority of their training. It was obvious that withdrawing permit free training was pointless if there was this alternative route. The Chairs of COPMeD and English Deans went to see the Minister in July 2006 to express our concerns. In the event, because of the judicial review brought by BAPIO, and the permission given to appeal when the case was lost by them, no changes were made and those with HSMP status and their dependents were deemed eligible for the first round of application. This increased the numbers expected to be eligible for the first round of application by many thousands.

4.   What are the principles underlying MMC and are they sound?

  COPMeD fully supports the principles of MMC as set out in the MMC Policy Statement:

5.   To what extent have the practical implementation of MMC been consistent with the programme's underlying principles?

  5.1  The first stage in the MMC reforms was the introduction of the Foundation Programme, which was done according to the principles of MMC. Three features made Foundation Programme implementation successful: 1. Pilots; 2. Funding to support the reforms; and 3. A match between the number of posts and the number of eligible applicants, so that all eligible applicants were appointed into the new structure.

  5.2  In order to ensure the principles of MMC are reflected in implementation, COPMeD believes that there is now an urgent need to focus on modernising the content, delivery and assessment strategy of specialty training programmes. This work is already well underway, and the new, PMETB-approved curricula are being implemented, but the momentum must not be lost.

  5.3  The postgraduate specialty schools that are being set up in each deanery/SHA in England, in partnership with the royal colleges, provide a structure in which this can occur. There is a need for reliable sustained funding for this important work. Clinical and educational supervisors, training programme directors and heads of specialty schools all need time, training and administrative support to carry out their roles effectively. Consultant and GP expansion is needed to support the service while time is freed for the intensified training that will be required to train the new generation of specialists within a 48 hour working week—as will be required by the WTD—by August 2009.

6.   The strengths and weaknesses of the MTAS process

  6.1  COPMeD accepts the analysis provided by Sir John Tooke in his Inquiry.

  6.2  The previous system of SHO recruitment by application to individual hospitals for individual posts or rotations was inefficient and ripe for modernisation. National electronic recruitment had the potential to reduce the workload on consultants and deaneries, and hence the cost and service impact of recruitment.

  6.3  In order to do this effectively, there needed to be a reliable means of sifting out ineligible applicants electronically. There also needed to be a way of electronically ranking applicants where the volumes and competitiveness were high, so that consultants did not have to score every application. Neither was available. COPMeD strongly supported the introduction of a national computer-marked test, as is used in GP selection, which all applicants would have to take in order to apply for specialty training. Without this, or any other reliable metric to use for shortlisting purposes, the potential for an electronic process to cut down the workload for consultants was severely restricted.

  6.4  Lessons should be learned from the US National Residency Matching Programme, which requires all applicants to have taken the USMLE. This is an invigilated exam, covering basic sciences, clinical skills and knowledge. The scores from this are obtained directly from source, eliminating fraud. Applicants may apply for as many programmes as they wish. Local programmes use this metric to sift applicants, supplemented by local criteria, depending on the popularity and character of the programme. This approach allows trainees to "earn the right to choose". It rewards diligence, encourages learning and provides a level playing field for applicants whatever their place of qualification or experience.

  6.5  COPMeD recommends the commissioning and piloting of a computer-marked selection test to be taken by UK medical students in their final year and by all external applicants seeking postgraduate training in the UK. Such a test must provide a means of electronically ranking applicants in a way that is valid, reliable, fair and transparent. Such a selection test could be designed to elicit the characteristics of patient-centredness, breadth as well as depth of knowledge and the ability to solve problems.

  6.6  A national electronic recruitment process for specialty training should be re-introduced in the UK only when we have developed a reliable metric for ranking applicants electronically. Once that is available, we will be able to cope with high volume applications, and can proceed to a specialty specific selection centre approach for a manageable number of applicants. This is what COGPED has successfully implemented over several years, and the same principles could be extended to cover all specialties.

7.   The degree to which current plans for MMC will help to increase the flexibility of the medical workforce

  7.1  In order to make the medical workforce more flexible, trainees need to experience working in a variety of settings, for a range of providers. They need to be actively engaged in service reform, and be exposed to medical role models who embrace and champion change. They should be educated to consider the patient holistically, to put the patient's needs before their own and to balance the service as a whole against the needs of the individual patient. All of these are features of MMC training.

  7.2  The current plans for MMC include modernised curricula that have been developed in consultation with the service; e-portfolios that capture experience and skills gained; work-place based assessments that ensure trainees are reliably and demonstrably competent in their specialty. Such documented acquisition of competencies should allow trainees to move more easily between specialties.

8.   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

  8.1  COPMeD had a co-ordinating role for the postgraduate deans across the UK in the design and implementation of MMC. Most postgraduate deans were involved in one aspect or another of the design and all were involved in the implementation.

  8.2  The COPMeD Recruitment and Selection Steering Group was set up when, in March 2005, one of the postgraduate deans was commissioned by the UK Strategy Group to develop person specifications, selection criteria and the application form for the specialty selection and recruitment process. This group reported to COPMeD and JACSTAG among others and was accountable to the UK Strategy Group.

  8.3  COPMeD and the Academy of Royal Colleges came together to agree the entry criteria, person specifications, selection criteria and the application form in the Joint Academy COPMeD Specialty Training Advisory Group, which advised the UK Strategy Group.

Prof Elisabeth Paice

Chair of COPMed

January 2008

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2008
Prepared 8 May 2008