Tuesday, March 27, 2007

Uk Medical Training

The article below is repreoduced with the consent of the Author Dr Clive Peedell , a Consultant in Oncology

A crisis in UK medical training – how the government and the medical hierarchy have betrayed junior doctors and the public.

On Saturday the 17th of March 2007, Remedy UK, a new doctors’ pressure group, led an unprecedented march of 10,000 doctors through Central London from the Royal College of Physicians to the Royal College of Surgeons to protest about the predicted unemployment of thousands of junior doctors this August and the dumbing down of UK medical training. The medical profession is currently facing its worst crisis since the inception of the NHS. What has caused this uncharacteristic public outburst from the profession?

The United Kingdom has a very proud tradition of medical training. Doctors from all around the world come to the UK to work in the NHS and sit postgraduate exams set by the various Royal Colleges. These exams are respected the world over and only high calibre individuals get through the examination and training process to become Consultants and GPs. Traditionally, trainees (including many from overseas) have provided an invaluable service commitment to the NHS, which is also a vital part of training. They have kept the NHS afloat despite a significant shortage of doctors compared to other European countries. Despite this excellent and respected system, there were still problems such as failures in manpower planning for certain specialties, inconsistencies between the various colleges in training methodologies, and unfair selection processes. However these problems were gradually being ironed out.
We had a system that was highly respected, reacting well to new teaching and assessment methods, and working generally well. Why did the government want to change it and how have they gone about it?

Tony Blair sees doctors as resistant to change as evidenced by his “forces of conservatism speech”. The medical profession enjoy a high public trust rating unlike politicians and this poses problems for a government intent on radical reform of the NHS, which is opposed by many within the medical profession. In addition, senior doctors are very well paid and enjoy good pensions, so are therefore problematic to an NHS in constant financial difficulty. The way forward for government was to disempower and downgrade the medical profession by making it less influential, cheaper and easier to control. How?
The government has used various tactics to reduce the power of the medical profession including changes to the way doctors are regulated (Good Doctors, Safer Patients) and using the National Institute of Clinical Excellence to decide on which drugs and new medical treatments should be made available to patients. However, the most important move by the government was to remove the responsibility of postgraduate education from the Royal Colleges and hand it over to a new statutory body called the Postgraduate Medical Education and Training Board (PMETB). At the same time a new framework for postgraduate training called Modernising Medical Careers (MMC) designed by the CMO, Sir Liam Donaldson, was introduced. In short the government now controls the way doctors are trained. Their main aim is to downgrade professional standards, producing a cheaper, leaner, more manageable subconsultant grade of doctor ideal for non-complex routine work in Foundation Trusts and Independent Sector Treatment Sector Centres (ISTCs). An added “bonus” is that this new grade of doctor will have compatible qualifications with European “specialists” who could then apply more confidently for jobs in the UK, flooding of the medical labour market, allowing Foundation Trusts and ISTCs to take advantage of market forces. This all sounds good for the taxpayer, but it flies in the face of the NHS Plan 2000, which promised the public a consultant led service and excellence in healthcare. In addition, the subconsultant grade will be damaging to morale, ambition, service building and development, research, teaching, and ultimately, professional standards. Quality of care is likely to suffer and our brightest young people will shun medicine as a career. These issues have been the cause of great angst within the profession and hence secrecy and denials from the DH and Royal Colleges about the “subconsultant grade”, although more recently this has come out in the open following quotes and statements from Professor Sir Alan Craft (ex President of the Academy of Medical Royal Colleges) and Professor Alan Crockard (Modernsing Medical Careers National Lead, ex Royal College of Surgeons training lead).
Craft is quoted: “Certificate of completion of training (CCT) holders will need to work in teams to ensure patient safety”
Crockard is quoted: “it will be up to employers to decide at what level they wish to employ doctors who have attained CCT”

The medical profession has been stunned by these rapid changes and is asking itself why the Royal Colleges allowed themselves to be disempowered in this way.
The answer lies with a “Carrot and stick”. The “Stick” was provided by recent medical scandals (e.g Shipman, Ledward, Bristol, and Alder Hey), and the European Working Time Directive (causing reduction in doctors’ hours). The department of health used this “Stick” to beat a weak Royal College leadership into handing over power to the PMETB. They also had to accept the plan for the new competency based training system, Modernising Medical Careers (MMC). College insiders tell me that the DH played hardball with phrases like “This is happening whether you like it or not. You are either in or out”. The “Carrots” included positions on the board of PMETB for Royal College members and other powerful positions. For example, the current President of the Academy of the Royal Colleges (which oversees the 14 Royal Colleges), Dame Professor Carol Black has been appointed Chairwoman of the Honours selection committee for health service staff. I was disappointed to see that she accepted this position when there is a clear government agenda for complete control of the medical profession.
In short, the medical hierarchy, although initially very sceptical, has been complicit with the department of health in forcing through these draconian changes despite opposition from the BMA and grassroots doctors. They have shot themselves in the foot and their own profession in the back. They have betrayed an entire generation of junior doctors. A recent quote by Professor Ian Gilmore President of the Royal College of Physicians in the British Medical Journal (http://www.bmj.com/cgi/content/full/333/7575/969), suggest that at least some of the college hierarchy now regret their actions:
“We should learn from the lessons of postgraduate education, where the royal colleges' oversight has been lost to others. We need to stand up and take responsibility for demonstrating that patients' trust in their specialists is justified.”

It is modernising medical careers (MMC) that is now causing all the angst amongst doctors. The original plans were to replace the Senior House Officer (SHO) grade and develop a seamless training structure for junior doctors that would mean less interviews and less migration around the country on the way to becoming Consultants and GPs. Much of the content in the original document was laudable and it even included the word “consultant”. Unfortunately, drastic changes enforced by the DH including the plan of the subconsultant grade, rushed implementation, a lack of training posts, and poor communication from the MMC team (despite a team of communications officers) has lead to unprecedented protests and concerns from the profession. The final straw has come in the last few weeks with an untested and unvalidated computer selection system called the Medical Training Application Service (MTAS) that appears to have gone disastrously wrong and angered the medical profession to its core. To summarise, 33,000 junior doctors had to use an online computer system (MTAS) to apply for 22,000 training jobs simultaneously within a two week period, followed by a similarly short period for consultants to shortlist candidates for interview. A scoring system was employed that heavily weighted scores to “woolly” questions more suited to creative writing than traditional academic achievements. The problems encountered are too numerous to list, but included computer crashes, loss of applications, and doctors being selected for interviews in specialties they had never applied to. The most comical glitch I have come across was a consultant surgeon involved in shortlisting who was sent an interview date for a training job! Not surprisingly this has hit the headlines and a review of the MTAS process has been ordered by the Secretary of State for Health. There are grave concerns that some of the best candidates have not been shortlisted and this lead to one group of surgeons in the West Midlands to abort the interviews of 82 candidates on the day of the interviews. Other groups have followed suit since. Incredibly, although the MTAS review group described a “crisis in confidence” in MTAS, they have agreed that round 1 of the selection process should proceed on the basis that unsuccessful candidates in the first round will get the chance of securing jobs in the second round. However, this will leave those who may have been victims of a flawed selection process with much worse odds of getting a job in the second round, because most of the coveted training posts will have been taken up in the first round. The fact that 33,000 doctors have applied for 22, 000 training posts will make this inevitable in the more competitive specialties. In addition, a third of these posts are short term posts only that will lead to further unemployment a few years down the line. Worse still, most of the ensuing unemployment will be reaped upon our most qualified and experienced SHOs because of the greater numbers of doctors in this group and the lower proportion of jobs available to them. Thousands will end up leaving the country with likely detrimental effects on service provision as well as wasting over a billion pounds of taxpayers money. There are clearly very serious implications for the careers of these doctors as well as their financial and family situations. This is a truly scandalous situation in wealthy country with a shortage of doctors compared to other European countries.

Despite the MTAS farce making the headlines, it is actually the whole MMC process that is the problem. Those who are successful in getting jobs are heading for a lifetime service commitment subconsultant grade with little chance of making it to full consultant level. Medicine will become a poor career option. The nation’s health depends on producing high quality doctors. Some changes to the old system were needed in view of changes to the working hours of doctors and a changing medical world, but the ill thought out MMC framework, which completely lacks any serious evidence base, is in my opinion politically motivated and not geared to the needs of patients. It needs to be stopped immediately pending a independent review.

We live in a democracy and I would accept the introduction of a subconsultant grade of doctor if that is what the public wanted. However there has been no consultation with the public who were promised a consultant led service in the NHS Plan 2000. We need an urgent public debate on this matter.

The government is attacking what is sacred to all doctors – medical professionalism. We will not go down without a fight and we have a new organisation to help us called Remedy UK.

If the journos out there are reading this then please pass it on

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