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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 April 7; 334(7596): 724.
PMCID: PMC1847889
Body Politic

The royal colleges must up their game—or die

Nigel Hawkes, health editor, the Times

The debacle over doctors' specialist training begs the question of what the royal colleges are for

The debacle over medical training has left the Royal Colleges feeling bruised, but they are in no mood to blame themselves for what went wrong. Their response is one of injured innocence: they feel just as much victims as do the young doctors denied a fair chance of a training post. Your pain is our pain; and whatever went wrong with the Medical Training Application Service (MTAS) had nothing to do with us.

Professor Neil Douglas, president of the Royal College of Physicians of Edinburgh and the man chairing the panel trying to clear up the mess, said that he personally was annoyed at the “negative spin” blaming the colleges for the process.

Let's grant him this much. The colleges are deeply implicated in Modernising Medical Careers (MMC), but may perhaps escape a guilty verdict over MTAS. Since Professor Douglas hails from Edinburgh, we might opt for the excellent Scottish verdict “not proven.” That allows the charged man to walk away, but leaves the onlookers quietly shaking their heads.

MMC has always been a puzzle to me. When I have asked deans and officials why it was launched, their responses have fallen disappointingly short of a complete explanation. They generally say that it was meant to deal with the “lost tribe” of senior house officers, forever seeking an opportunity for advancement but never quite finding one.

Maybe, but that hardly seems to justify the wholesale redesign of a system that had produced good doctors, especially as MMC offers plenty of new ways of sidelining those who don't quite make it.

The question the royal colleges have to answer is how and why they became complicit in a system for postgraduate education that meant they had no influence on MTAS until it was too late. Nobody can say they weren't warned. Last year's furore over appointing F1 doctors under MMC went horribly wrong, and produced a lot of injustices. Yet nobody did anything to correct the defects until exactly the same thing happened again, on a much bigger scale and with even greater injustice.

What, exactly, are the royal colleges for? Postgraduate medical education has always been a central role, and examination fees a major source of income. The purpose of MMC, it seems to me, was to wrest control of higher training from the colleges, and shape it in ways designed to suit the employers. The colleges were placated (a cynic might say bought off) by allowing their exams and their income flow to continue, at the price of having little further influence.

Many of those who take the exams hail from overseas. The colleges did not want this source of income to dry up either, but nor did they want foreign graduates to take up too many of the training opportunities. Hence the rage of Professor Allan Templeton, president of the Royal College of Obstetricians and Gynaecologists, who in an email to Dame Carol Black, chairman of the Academy of the Medical Royal Colleges and former president of the Royal College of Physicians of England, complained that the completed forms “fail to identify UK graduates, which we all thought was the major purpose of MMC.” Ouch!

How did the royal colleges allow MMC to become a branch of the Department of Health? This government has been extremely skilful in erecting a Big Tent and inviting all those with influence to step inside. The best example was the NHS Modernisation Board, a classic of inclusion politics. This body was meant to advise the secretary of state, giving those who served on it a tiny taste of power and implicating them subtly in the decisions taken. It produced three reports and then fell silent, its task done. It has since been abolished.

Whatever the reasons, many doctors now feel that their colleges have failed them, and on an issue central to the profession of medicine. “I for one am ashamed to be a member of a royal college which, once so apparently omnipotent, now simply appears impotent and inert,” wrote one doctor to Professor Douglas. It's unlikely his is a lone voice.

British organisations tends to follow a pattern. Formed to promote shared interests, they enjoy a vigorous and effective youth, a mature but more compliant middle age, and sink finally into a dotage, where they simply exist. Examples of this final stage are the City of London livery companies—the Cordwainers, the Tallowchandlers, the Salters, the Pewterers, and Plaisterers—with their fine halls, excellent dinners, and their charitable donations. There are, astonishingly, still 107 of them, and long may they flourish—they do no harm and provide much innocent enjoyment.

But while the City does not have many (or any) tallowchandlers and cordwainers left, the royal colleges represent a living profession, which has never been more disaffected. Excluding the surgeons and the pathologists, both of whose colleges have displayed some bottle, this disaffection has gone largely unexpressed.

There's too much happening in the profession these days that is passing the colleges by. They need to raise their game and make clear they are independent bodies with their own ideas and principles—which may from time to time differ from the government's—unless they want to join the City fossils.

The purpose of Modernising Medical Careers was to wrest control of higher training from the colleges, and shape it in ways designed to suit the employers

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