The flight of the junior doctors
From Mmc
The flight of the junior doctors
By TOM RAWSTORNE Last updated at 00:35am on 24th March 2007
The government has adopted a dangerous stance that could result in the flight of thousands of young doctors from Britain Most popular stories
Logging on to his computer earlier this month, Dr Tim Nedas was delighted to discover that he had been short-listed for a job as a urologist.
The 28-year-old had been working towards the position for ten years – a decade in which he had dedicated himself to developing the experience and skills required to become a specialist in the National Health Service.
But with a second click of his mouse, the junior doctor’s delight turned to despair. The website crashed as he tried to arrange his interview and when he finally managed to get back on later that afternoon, Dr Nedas discovered that there had been a mistake, that he hadn’t been selected at all.
In fact, not only was there no dream job, come August there is the very real risk that he will have no employment at all.
"I was absolutely distraught and still am," Dr Nedas said. "I don’t know what to do with the rest of my life. I go into work and I am absolutely miserable. I have worked my guts out since I qualified, I have all this drive to succeed and then the rug is pulled from under my feet. I wander around on my ward rounds thinking: 'Why am I here?'"
It’s a question that is currently playing on the minds of junior doctors throughout Britain.
They’re the mainstay of the NHS and yet thanks to the Government’s obsession with centralisation, with meddling and interference, they are in open revolt. At least 9,000 face unemployment come the summer while three times that number are caught in the middle of a computerised recruitment system that is turning into a nightmare.
Last Saturday, dressed in white coats adorned with images of doctors stabbed in their backs and slogans proclaiming Doctor 4 Rent, the junior doctors took to the streets of London in the biggest medical protest march the country has ever seen.
Thousands more will be back on the internet today – this time scouring the web for details of job vacancies in Australia and New Zealand, countries that will treat the cream of Britain’s medical future with the respect they deserve.
It’s not ingratitude that has driven them to take their skills (learned at a cost of £250,000 a head, paid for by the taxpayer) abroad.
Rather, as a Daily Mail investigation reveals today, this brain drain is being driven by the incompetence of their political masters. Under the auspices of Health Secretary Patricia Hewitt, the system of career progression that has successfully turned junior doctors into specialists and then into consultants for generations has been replaced with an initiative known as Modernising Medical Careers (MMC or, as doctors have dubbed it, the Mass Medical Cull.)
The introduction of the changes has created a "bottleneck" of applicants which this year will see 32,000 junior doctors chasing just 23,000 vacancies.
Professor Gus McGrouther, professor of plastic and reconstructive surgery at the University of Manchester, explains: "This is the biggest crisis to hit British medicine in the history of the NHS. We are sacrificing thousands of young doctors who are partially trained and committed to a career in the NHS. I cannot find a single doctor who is happy with this flawed process and ultimately it is the patients who will suffer." To fully understand the depth of feeling, it is necessary to understand the complex nature of the changes that are being implemented.
They affect junior doctors, a broad term that covers medics from graduation with a medical degree to their becoming a specialist or a general practitioner. Indeed, the term "junior" doctor is misleading as many will be skilled doctors with years of experience.
They are the ones who must comfort and treat patients in packed accident and emergency departments, overflowing admission wards, and intensive care units.
The MMC reforms were introduced to let junior doctors climb the career ladder more quickly, reaching consultant level in an average of 11 years, rather than 14. Under the old system, junior doctors spent four years doing their initial training before applying for a post working full-time in a specialist area, but that has been reduced to two.
Because the reforms were instituted in 2005 it means that this Spring those who have been through initial training in both old and new systems are applying for posts at the same time. As a result there are insufficient jobs to go round.
This bottleneck has been made much worse because under the old system hospitals advertised training posts individually throughout the year. It meant that if the applicant failed once they could have another go when another job came up somewhere else.
Under MMC everyone applies for the jobs at the same time and everyone starts at the same time – 1 August.
This mass exercise in re-employment is handled by the NHS-run Medical Training Application Service (MTAS).
Under this system, junior doctors would apply for four posts over the internet and would be short-listed for interviews. Unsuccessful candidates would then go through to a second round where they would have a final chance to fill any remaining places.
That was the theory. The practice has been very different.
For starters, the online application form is radically different from what has gone before. In the past the selection of junior doctors was based on their academic achievements, their research, their references and their extra curricular activities.
The new forms, however, require applicants to complete a series of 150-word vignettes about clinical cases or ethical issues. Three-quarters of the marks available would be awarded for these passages of purple prose with the remaining quarter for actual clinical and academic qualifications.
Put simply, getting short-listed was more a matter of creative writing, of verbal box-ticking, than clinical excellence. Got a PhD? That’s worth one point. Got something eloquent to say about coping with stressful situations? Have four.
That this is indeed the case is underlined by the fact that a series of companies are now offering medics coaching on how to best fill in the forms. For instance, apply2medicine.co.uk offers an online editing service that costs £549.
Doctors simply email over their responses and the company will "improve them" and send them back.
The sales pitch states: "As our service is sure to reach capacity quickly we would recommend that you purchase our editing service as soon as possible to ensure that we will be able to help you."
A testimonial from a satisfied customer reads as follows: "Great help. It is only trivial changes in somebody’s application form which make all the difference between a successful and non-successful one."
Another service, a £39.99 guide, promises: "This comprehensive guide will take you through the types of material you could use for the question asked on the application and how to formulate your answers to help improve your score."
Quite why the assessment procedure has been so radically changed is unclear. But there is a suspicion that the NHS is under pressure to ensure the new system does not compromise applications from nationals from the rest of Europe, in case the government falls foul of European law. For this reason, a significantly reduced emphasis has been placed on traditional criteria that would have benefited British high-achievers.
In practice, the upshot of these changes has been that those who have had to sift through the applications and to prepare interview shortlists have been faced with a near impossible task. Not only are the application forms less informative, but the consultants involved in the shortlisting process are not even shown the entire form.
Instead, they are given the answers to one, single question and asked to mark it for all the candidates. The idea behind this blind marking is to ensure fairness and remove individual bias. In reality, it has meant that some brilliant young medics have failed to secure a single job interview.
Professor Gill Livingston, professor of psychiatry at University College London, explains: "One of my colleagues has been shortlisting and was presented with one question from an application form, rather than the whole form. Clearly the junior doctors had not been told that was going to happen and so in the context of the whole application form some had referred to an answer they had given to another question, entering 'see question so and so' in the space. How do you mark that?
"Also, the questions didn’t actually cover their job but rather things that weren’t intrinsic to their job – this may show a level of enthusiasm but it won’t show how good you actually are at your job."
Further, software problems meant that the assessors were often unable to access the forms online. Instead, delays built up and in the end they were forced to print out hundreds of forms and review them in hard copy.
"My colleague was told he would have several days, but in the end he was given the forms one morning and asked for them back within 24 hours," says Professor Livingston. "There were 700 applicants and so that worked out at about 40 seconds per applicant. Many doctors have been shortlisted for posts that they never applied for – two psychiatrists were offered posts in paediatrics."
Other bizarre marking anomalies exist, one of which is the weighting given to experience. It seems a good idea, but the effect has been that it has favoured doctors who have failed their exams and so progressed through the ranks more slowly.
"I presume this is a mistake," says Professor Livingston. "It is almost as if they tried to design a system that is as inefficient as it could be. We had misgivings all along but we didn’t think it would be as bad as this. I thought at least the process would be somewhat fairer and didn’t think people who were excellent at their job wouldn’t be shortlisted and therefore totally demoralised."
As the scale of the problems became apparent last week consultants threatened to boycott the interviews because they had no confidence that the right candidates' posts were being selected. Andy Garnham, consultant surgeon at the Royal Wolverhampton NHS trust, was a member of a West Midlands panel that decided to withdraw from the recruitment process.
He said: "We have a duty to the public to make sure that the best doctors are chosen. There is always competition for jobs and that is right that there should be. But that competition should be fair."
With the revolt spreading, the Department of Health announced an urgent review. The upshot was that all candidates who had been previously selected for interview would still be interviewed but trained medical advisors would now go back and examine in detail the candidates who were left out first time round.
But to the anger of many junior doctors Patricia Hewitt, the Health Secretary, has refused to scrap the system. On Monday, in an emergency debate in the Commons, she said it would be "completely absurd" to revert back to the old way of doing things. It’s a dangerous stance to adopt, as there are more problems ahead.
Dr Matt Jameson Evans, a spokesman for RemedyUK, a pressure group that represents 8,000 junior doctors, explained: "Traditionally, different specialties changed their medical staff on different days, and not all members of a team change together. But the present government-imposed reforms require that this year all the junior doctors must change jobs simultaneously.
"Patient treatment will be hit because there will be no continuity of medical care. There may be nobody left in the hospital who fully understands the medical history of individual patients, or who understands the hospital processes and routine."
Further, it is understood that legal challenges are being prepared on behalf of a number of applicants claiming that the procedures were unfair and failed to follow accepted practice.
Many medics are expected simply to up sticks and move abroad. A recent survey found that 50 per cent of junior doctors said they would emigrate if they failed to land a job.
Dr Claire Cooke, 28, who spent five years at medical school at St George’s Hospital in London and who has undergone five years post-medical school training, is one of them. She currently works in a hospital in south-east England and refused to take part in the MMC application process.
"For the last five years I have always wanted to be a surgeon but this whole shamble has made me reassess that," she said. "The type of doctor this system is attempting to create is not the type of doctor that I or any of my colleagues want to be."
She believes that the Government’s streamlining of training will result in doctors whose skills are far more specific and whose experiences are less broad. "Doctors will do less of the peripheral training that makes you a much better and rounded doctor able to cope with emergency situations. Instead they are creating a legion of rigid, inflexible automatons."
She adds that she refused to apply because "after all the hard work I have done to get where I am, I just wasn’t prepared to beg for the scraps from the table".
"The application form was such a crude and ineffective tool for selecting doctors," added Dr Cooke. "It might be effective in industry or in general practice, but you can’t select hospital doctors by a creative writing process. It literally was a lottery."
Instead, she has decided that she will move to New Zealand. Other doctor friends, she says, are off to Australia.
"Some friends recently returned from Sydney and said the consultants out there are rubbing their hands with glee," she said. "British doctors are well-respected and recognized as among the best trained in the world. They can’t believe their luck."
But for the people of Britain, who rely on the NHS, it is very bad luck indeed.
