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Another fine mess the Department of Health has got doctors into
“Although a deeply damaging episode for British medicine, from this experience must come a recommitment to optimal standards of postgraduate medical education and training. This can only occur if a new partnership is struck between the profession and the DH [Department of Health], and between Health and Education. Each constituency has been found wanting thus far. In future, each must play its part. An aspiration to clinical excellence in the interests of the health of the population must be paramount.”
So concludes Professor Sir John Tooke's inquiry into Modernising Medical Careers (MMC).1 2 This initiative, “an honest attempt to accelerate training and assure the fundamental abilities of the next generation of doctors” almost foundered over the failure of its main component, the centralised selection into run-through specialist training. In response, the government announced an independent inquiry into MMC, the interim report of which was released this week. While Tooke's report runs through the reasons for the failure of the Medical Training Application Service (MTAS), these have been extensively covered in a previous report.3 Sir John's canvas was much wider. His panel “explored the background and context—in medical terms the predisposing or aetiological factors—that may have contributed to the perceived problems with MMC, rather than simply focusing on MTAS.”
So, what went wrong? Wherever Sir John shone his torch he found debilitating vagueness and frailty. He found no evidence of a consensus on the educational principles guiding postgraduate medical training and that mechanisms for creating such a consensus are weak. The management of postgraduate training is hampered by unclear principles, a weak contractual base, a lack of cohesion, a fragmented structure, and, in England, deficient relationships between academia and service. No consensus exists over doctors' roles at various career stages, which hampers planning of the medical workforce. A vacuum exists in policy regarding the potentially massive increase in trainee numbers. And so on.
At the press conference launching his report, Sir John refused to name and shame the guilty parties, but because he listed governance and risk management as most at fault they are most likely to reside at the Department of Health. In mitigation, responsibility for MMC was split between two people and the biggest headaches—MTAS4 and the surfeit of eligible international medical graduates5—were outside the responsibilities of both of them. Also this week, the government announced that there would be no national IT system for job applications next year and that it was launching a consultation exercise over training jobs for medical graduates from outside the European Economic Area.6
How had the stewardship of medical training deteriorated to such an extent at the Department of Health? Benign or malign neglect? Conspiracy to further deprofessionalise doctors or cock-up? Once again Sir John would not be drawn, but the manifest organisational failures of the department would suggest that conspiracy was beyond its skill set.
The bottom line is that the department has wrested control of doctors' training from the medical profession and has proved itself unequal to the task. One of Tooke's “corrective actions” concerns the Postgraduate Medical Education and Training Board, set up to regulate postgraduate medical education in the wake of the Bristol inquiry. He wants it merged with the General Medical Council, which already regulates two of the three components of medical education (undergraduate education and continuing professional development). Crucially, “it is a body that reports to parliament, rather than through the monopoly employer.”
Doctors don't emerge unscathed. “Forensic” analysis of meeting records shows they were well represented on the various delivery and advisory boards—one figure in the report lists an alphabet soup of 19 different representative bodies, with their dates of attendance. But in sum their influence was “suboptimal.” Their frequent calls for trialling and delay went largely unheeded, and they reported being deterred from questioning policies. On occasion, they weakened their impact by speaking up for their individual consistencies rather than for the profession as a whole, according to the report.
The report recommends that the medical profession urgently needs to develop a way of providing coherent advice on matters that affect the entire profession, without giving details of what this might look like. And it wants a consensus on the role of doctors to be agreed by the end of 2008. Sir John admits it's a tall order, but it would coincide with the 150th anniversary of the Medical Act, something that obviously appeals to a doctor who quotes William Osler and medical historian Roy Porter in his foreword.
For the doctor on the ward or in the clinic the biggest changes will be those recommended for the structure of postgraduate training. The need for a broad based beginning, flexibility, and the promotion of excellence recur like a mantra throughout the report. Sir John says this part of the report was heavily influenced by the workshops he held throughout the United Kingdom, which involved 450 trainee doctors. They said that they wanted to be much better than “just good enough” for their jobs (hence the report's title, Aspiring to Excellence).
The report recommends that the link between foundation years one and two is broken, allowing the second foundation year to become the first of a three year core training programme (along with the first and second years of specialist training). Up to half a dozen defined core programmes (including ones in surgery, medicine, and general practice) are envisaged, which would involve six appointments of six months each. These core programmes would serve as stems for subsequent specialty training.
Entry into higher specialty training after the core programme would be based on marks obtained in national assessment centres for the specialty in question, together with structured CVs and interviews for shortlisted candidates at deanery level.
General practice training “must be extended to five years to assure the skill base of that part of the medical workforce that is going to become increasingly important, with rising longevity, increasing co-morbidity, and shifts of care to the community.” And the future of doctors in fixed term specialty training appointments and in the non-consultant career grade needs to be sorted out.
If Tooke's recommendations for the early years of training sound familiar it is because they resemble the proposals for senior house officer training set out in Unfinished Business, a consultation paper dating from 2002. Its principles were that training in these early years should begin with a broad based programme and be flexible to trainees' needs, providing opportunities to leave and re-enter. However, a subsequent document reported that “thinking had moved beyond the basic specialist programmes foreseen in Unfinished Business” towards a single “run-through approach,” a shift recently discussed in these pages.7 Tooke's comment, “although whose thinking and with what authority is not entirely clear,” could stand as his verdict on this whole sorry chapter of Modernising Medical Careers.
And as to the next chapter? Richard Hayward captures the challenges well in his personal view this week, “the MTAS fiasco (for which all parties must share responsibility) stands as a dire warning to government and medical profession alike of trying to reform health care without cooperation between the two. Expect the current rocky ride to continue until and unless the government and the community of independent medical practitioners find common ground—something that will require a shift of culture on both sides if the NHS is really to benefit.”8 Tooke has provided the roadmap for postgraduate medical education and training.
Competing interests: TD's wife qualified in the European Economic Area and shortlisted and interviewed for the London Deanery.
Provenance and peer review: Commissioned; not externally peer reviewed.