Response from FIDELIO to proposals from the MMC Programme Board

Introduction

Thank you for the belated request to contribute to feedback on proposals for MMC 2008. We hope the short notice does not reflect any lack of genuineness in the consultation exercise. It is vital that senior members of the medical profession can contribute more than a cloak of respectability to changes which threaten the careers of our junior colleagues, and the health of the NHS as we have known it.

We agree that the forecast rise in competition increases the importance of rendering the process less random than in 2007, when some of the best applicants failed to gain posts. However, we find it bizarre that the current proposal devotes just one sentence to the growing competition, and the rest to details of process. Until the MMC debacle, graduates of UK medical schools could expect a training in some branch of medicine, albeit with stiff competition for entry to the most desirable branches. Within two years, without discussion, we have gone to a situation where first a quarter, and next year perhaps a half of graduates will fail to enter training. Whether this is due to a deliberate strategy to weaken the power and prowess of the medical profession, or to pure incompetence, there needs to be a serious and urgent public debate – within and without the profession – about the numbers, and who is responsible.

The DH may look enviously at areas of the labour market where an influx of workers from abroad appears to have reduced costs and increased quality. It may consider that, if the profession complains, medical schools can close and still leave enough doctors to staff the NHS. It is the responsibility of the profession’s leaders to point out that, unlike these areas, UK medicine has been the envy of the world, but will only remain so if pursuit of excellence remains its primary goal.

The Board’s proposals

Like most of the responses that we have seen, we welcome the ability of the Board to take a more common-sense and cautious approach than followed by the evangelists of 2007. Of the options offered, it will be no surprise that our favoured would be those which minimise central control, and maximise both local and individual choice.

However, we will not reply to the individual questions because none of the options is satisfactory. The truncated time-scale for making decisions for 2008 is entirely of the DH’s own making, and should not be used as an excuse for taking any further steps to the detriment of the medical profession before the Tooke Review has reported. Had we been at the table, we would have suggested that the model for designing 2008 should be the last year before the DH-inflicted catastrophe, namely the local competitions of 2006; and that discussions should focus not on inventing new procedures for competition, but on the major serious issue of the predicted 3:1 competition for places. We repudiate the notion that this DH Board can simply say that manpower issues are outside its remit, since the problem is all about – and created by – the manpower issues.

For large swathes of Medicine, the Calman SpR system worked well; even the lost tribe of SHOs turns out to have been a problem of a relatively small number of pockets such as plastic surgery, urology. Whether Tooke will agree that MMC was a sledgehammer to crack a nut, we await to discover. But meanwhile the selection procedures for large swathes of Medicine should simply not be altered from 2006. In particular, we should not repeat the 2007 decision to exclude from involvement the one group of individuals most skilled in the process of running SHO selection – the Medical Staffing Officers of individual Trusts. While their quality doubtless varies among Trusts, many are excellent. It was this group, ironically, who largely kept egg off the DH’s face in July/August when given just 3 weeks to place half the applicants of 2007 – something the MMC/MTAS apparatus had failed to do in six months.

Although, as discussed below, opening-up ST3/4 posts has to be considered, most of the pain this year will be at ST1 level. So effectively the MMC Board is trying in a few weeks to improve on what MMC spent 7 years trying to do. Meanwhile the problem has become much worse because of the increasing competition. Instead of trying to invent rules at short notice for ‘bucking the market’, and infringing free competition, the Board should return ST1 appointments to individual Trusts, without limit on number of applications, and concentrate its efforts on considering whether and how the degree of competition can be improved. This can be done in two ways: increasing the denominator, or reducing the numerator. Both are possible as follows.

Increasing the numerator (i.e. number of jobs)

In 2007, the number of ST1 posts could not be based on the previous number of SHO posts because no reliable estimate of this existed. Instead the number (we assume) was a cross between a guesstimate of the previous number, and the slightly more reliable estimate of available ST3 posts into which the ST1 would run. This calculation was clearly very approximate because – under pressure from the BMA and others – the numbers changed dramatically at a late stage. However, since there has been no transparency on how the numbers were arrived at, we have little confidence that the number takes into account any reliable estimates of wastage, part-time working, and effects of EWTD etc. Since the effect of the latter, in particular, is dramatically to reduce available number of junior doctors, we should be seeing an increase – not decrease – in the number of available posts!

The Board recognises that insufficient markers of excellence exist to permit rational selection for training among FY2s – interestingly, a rather sad indictment of what MMC is delivering even in the trumpeted foundation years. Therefore, there must be continued training for all UK graduates up to the point where rational selection can be made.

One easy way to swell the number is to drop the artificial distinction between ST1 and FTSTA. There is little or no evidence that we have seen at local level of a dramatic change in training consequent on the change from SHO to ST1 status – for all the grief of this year, not much seems to have changed other than the introduction of misleading grades on name badges. So we propose that, at least until Tooke has reported and been absorbed or otherwise, all doctors undertaking service work of the level expected from SHO/ST1-2 doctors should be regarded as in training; and sufficient posts made available – allowing for EWTD – to ensure time off service work and attendance at formal teaching.

Reducing the denominator (i.e. no. of applicants)

Clearly the major factor here is the UK/non-UK issue, which cannot be resolved in a few weeks. But it must be confronted in a major document such as the present proposal; and if Tooke chooses to avoid it, then implementation of its recommendations is probably doomed.

Nevertheless we see two ways in which the DH via the Board can influence the 2008 denominator.

• This will be swollen in 2008 at ST1 level by applications from unsuccessful 2007 applicants. We are obviously pleased that the best among these are to have another chance, but these individuals should, one year on, be competing at a higher level. This depends on opening-up run-through as discussed below.

• The large denominator in popular specialties needs to be reduced by encouraging entry into shortage ones; and the overall denominator reduced in the long-term by reducing dependence of the shortage specialties on non-UK doctors. The low denominator in shortage specialties is just the sort of problem which arises when a free-market is over-regulated. General practice used to be a ‘shortage specialty’, but has been made more attractive through separate negotiation of pay and conditions. While this analogy may seem undesirable in the current climate, the fact is that the figure of only 0.5 UK applicants per place in specialties like O&G, and our long-term dependence on HSMPs, is a consequence of pretending that all areas of Medicine are equally attractive without allowing the market to create conditions that renders this true. The Board cannot resolve this problem in the coming week. But it has an important opportunity to encourage entry of UK graduates into shortage specialties; and to catalyse change in applicants’ career preferences by stating an expectation that these be influenced by de-regulation of career prospects and conditions among specialties.

Run-through

MTAS 2007 achieved the remarkable double of creating grief via the long-term consequences of both failure to be appointed, and the success of being appointed – but to a post from which there is little escape for the next seven years. Although we are often told that it was the Juniors who wanted run-through, this desire was of course contingent on most of them obtaining run-through – and, probably if unrealistically – on the assumption that most would obtain run-through in a specialty and region of their choice.

Clearly promises to appointees must be honoured. But this is not incompatible with considerable flexibility being re-introduced, that opens up appointments at ST3/4 level. As the Board’s document acknowledges, applicants vary in placing specialty or location as their priority. Many of the former are likely to swap run-through to Lesser-ology in St. Nowhere’s for the possibility of competing for Super-ology wherever a post is advertised.

Summary

1. We note with concern the expected 3:1 competition for training places, and request consideration of this be given pole position in the final proposal.

2. The Board should re-affirm that the education and training of medical graduates is not complete by the end of the Foundation years, and that only rigorous measures will be used to exclude graduates from continued training after this point.

3. Appointments of ST1 should be undertaken in the same way as SHO posts prior to 2007, until/unless firm recommendations to the contrary are made by the Tooke Review and agreed with the Medical Profession.

4. The Board should state that, in many specialties, Run-Through is an undesirable principle when a large proportion of graduates are excluded; and that commitments already made can be re-considered bilaterally for those putting specialty ahead of location as their priority.

The members of Fidelio will be delighted to help in the planning and implementation of our proposals.

Morris Brown

Nick Boon, President Cardiovascular Society

Peter Barnes, FRS

Stephen O’Rahilly, FRS

Mark Pepys, FRS

James Scott, FRS

Nick Brooks

John Camm

Angus Dalgleish

Jon Friedland

George Griffin

Tony Heagerty

Humphrey Hodgson

Juan Carlos Kaski

Chris Kennard

Kay-Tee Khaw

John Lazarus

Jim McKillip

John Monson

Philip Poole-Wilson

Jim Ritter

Bryan Rowlands

Neil Scolding

Doug Turnbull

Mark Wiles

25^th September 2007