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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 August 11; 335(7614): 284.
PMCID: PMC1941879
Body Politic

How not to win friends and influence people

Nigel Hawkes, health editor, the Times

The debacle concerning the UK medical training application service (MTAS) has flushed out what people really think of the Postgraduate Medical Education and Training Board

As the MTAS shenanigans have emerged it has been interesting to discover how many organisations and individuals are not responsible for it. Failure is an orphan, they say, but seldom such a threadbare and friendless waif as this.

Foremost among those who deny any responsibility is the government organisation charged with the higher training of doctors, the Postgraduate Medical Education and Training Board. Let's count the number of words in its name that relate to the issues affected by MTAS: education, postgraduate, training, medical. That only leaves “board” unaccounted for.

The board was supposed to bring organisation and method to the often haphazard arrangements for postgraduate education and training of doctors. In evidence to the High Court in the case brought by the campaigning group Remedy UK, the board acknowledged that it was responsible for laying down the basic principles of recruitment to specialist training posts. But its chairman, Peter Rubin, has said—rightly—that its powers do not encompass choosing between eligible candidates.

In disavowing responsibility for the mess he is at least in the best of company. When the chief medical officer, Liam Donaldson, was asked if he personally felt any responsibility for MTAS, he said: “The implementation went wrong. But responsibility is very widely distributed. It is very difficult to point to any single individual who could be said to be accountable.” I'll take that as a no, then.

Those who devise new policies or who are given the task of managing them are apparently unaccountable when implementation goes awry. Responsibility is so subdivided that, ultimately, nobody is to blame. But regardless of whether the board deserves criticism over MTAS the affair has at least flushed out what people really think of it.

It might be a slight exaggeration to say that the board is friendless, but there is little risk of being trampled in the rush to come to its defence. All the old animosities, swallowed at the time of its creation, have resurfaced. Even the Academy of the Medical Royal Colleges, normally not a body to foster discord, has expressed its anxieties in a nine page memorandum, leaked to the magazine Hospital Doctor, accusing the board of inefficiency, poor communication, bad judgment, and a reluctance to consult the colleges or even care what they think.

The academy should not have been surprised. The board was set up by Alan Milburn when he was health secretary, with the intention of clipping the wings of the royal colleges. Although nominally independent, it is largely a creature of the Department of Health. The colleges were allowed, on sufferance, to nominate members (through the academy), but it is the health secretary who makes appointments from the names put in front of him. Those appointed serve in their own right, not as representatives of the colleges.

The charges against the board include a lack of cooperation with the colleges, inefficient management (which has left many doctors waiting months for their qualifications to be checked), a high handed tendency to over-rule the colleges on whether candidates have done enough to justify a Certificate of Completion of Training (CCT), steep fees, and lengthy and complex application forms. As one senior college president put it, “We're not trying to turn the clock back, but we wanted a light touch regulator. What we got was a body with a large staff and an apparent desire to go into every possible detail.”

There is particular rancour over the board's readiness to overturn the colleges' advice over applications to join the specialist register. The colleges are paid for processing these applications—though not enough to cover their costs, they say—but their advice is often ignored, usually through the granting of registration to candidates that the colleges believe are unfit or insufficiently experienced.

Roger Greenhalgh, president of the European Federation of Surgical Specialties, called a meeting at the Royal College of Surgeons earlier this year of European surgeons, who agreed that only surgeons in a particular specialty were qualified to assess proficiency and competency. The board, by contrast, makes a point of excluding from its panels members of the same specialty as the applicant. Opinions among surgeons are running so high that in June the college passed, by an overwhelming majority, a resolution suggesting that the college dissociate itself from the board and take no part in its affairs until all the college's concerns are met in full.

The board's most cogent defence of its role came in its evidence to John Tooke's inquiry into Modernising Medical Careers. It argues there that in less than two years it has published standards for postgraduate training and approved curriculums across 57 medical specialties; issued more than 7500 CCTs; organised the first ever national survey of postgraduate trainees; and put in place a system for awarding CCTs to doctors who have not followed a formal training programme but have achieved the same levels of skills and knowledge as those who have. This long list of the board's achievements makes you wonder how we ever managed to produce doctors at all in the past.

The board's only concession to criticism is to admit that “any organisation would expect to take time to establish itself, and PMETB [the Postgraduate Medical Education and Training Board] is no exception.” Since the publication of the academy's memorandum, there have been meetings between the board and the colleges, with some evidence of a desire for compromise. One college president saw this as a chance for a new start but warned that the issue of whether the profession has lost faith in the board has not yet been resolved.

The charges against the board include a lack of cooperation with the colleges, inefficient management, high handedness, steep fees, and lengthy and complex application forms

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