Memorandum by the Conference of Postgraduate
Medical Deans (COPMeD) (MMC 57)
MODERNISING MEDICAL CAREERS
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: http://www.dhsspsni.gov.uk/response_unfinished_business
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
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