BOTA Submission to the Tooke Review
From Mmc
The MMC Inquiry: Recommendations from the British Orthopaedic Trainees’ Association
Key points
1.1.The direction of the future of healthcare within this country needs to be made clear in order to adequately plan for its delivery.
1.2.Organisations involved in the decision making regarding changes to training need to demonstrate a clear governance structure.
1.3.Those responsible for the recent unmitigated disaster must take responsibility for their actions.
1.4.Clinicians should govern the New Process.
1.5.The Postgraduate Medical Education and Training Board must consult and take advice from the Specialty Advisory Committees. Where the recommendation is for an increase in the level of training, that is, that the training should be more rigorous, this should be simply an affirmatory exercise. They must engage more, and become less bureaucratic and more facilitative in their approach, or be replaced by an organisation willing to provide the ability to improve specialist training.
1.6.The Specialty Associations, in conjunction with the Trainee Associations and the Royal Colleges should play a more prominent role in the design and implementation of the New Process.
1.7.There must be robust mechanisms for the selection, progression and exit of trainees with regards to thee training scheme.
1.8.We support the principles of less time spent at junior levels of training within allied specialties of a training scheme, clearly defined curricula, and competency assessment during training. We believe that these were the original views behind the MMC process, however these have fallen by the wayside and an emphasis inaccurately placed on Run-Through Training. We support the concept of Run-Through Training, but do not believe that the present plans provide a robust mechanism for its introduction. Trainees should be able to gather experience, and compete openly for training places at various levels of their training. Thus, entry into ST1, 2 and 3 should be available for appointment, for at least the next 3 years, with certain restrictions
1.9.Fostering excellence, as opposed to competency, must be the aim of all specialty training programmes.
1.10.The use of a centralised, electronic system as a repository for applications is welcome.
1.11.There should be no limit to the number of regions, specialties or occasions that candidates can apply for training posts.
1.12.The appointments process should include the use of a portfolio, to take into account CV, clinical experience, non-clinical experience, knowledge, and skills. These may be assessed in many different ways; however, all information should be available to appointments committees.
1.13.Entry into surgical Specialist Training programmes should occur after a robust test of knowledge, clinical examination assessment and communication skills assessment. Ideally this would be via a standardised test.
1.14.Flexibility should be present in the early years of training to move between specialties. It may be necessary for trainees to fall back a year if key competencies have not been attained, when changing from one specialty to another.
1.15.There should be opportunity to take part in research, and gain appropriate experience outwith the training programme, without the loss of the training number, in the pursuit of excellence.
1.16.Specialist Training Programmes should provide adequate training to the level of the definition of consultant, within the generality of the specialty. Funding for consultant posts should be associated with training numbers.
1.17.The definition of a Consultant should be detailed and made clear.
1.18.We do not support the establishment of a subconsultant grade by the introduction of run through training. Consultants appointed in the future should have the same “access“ to research, audit and teaching as part of their programmed activities. They should also have a minimum pay as defined by national pay and conditions but are free to negotiate supplementary benefits above and beyond these terms and conditions with their employing trust.
1.19.Plans for consultant expansion, including funding, must be detailed, clear, and used to inform trainee expansion
1.20.A small oversupply of trainees fosters competition and is beneficial. The idea of free-market competition within a monopoly employer is fallacious and misleading, and a large oversupply must be prevented.
1.21.Existing consultant hours should be brought into line with the European Working Time Directive, however they should be allowed to work beyond these hours on a voluntary basis should they wish.
Introduction
1.22.The British Orthopaedic Trainees Association (BOTA) welcomes participation in the Modernising Medical Careers (MMC) Inquiry.
1.23.BOTA represents trainees in Specialist Training in Trauma and Orthopaedics. Our membership is over 1050, and is the largest group of single-specialty trainees.
1.24.All of our trainees have demonstrated a commitment to a career in Trauma and Orthopaedics, and the vast majority of them hold National Training Numbers (NTNs) in Trauma and Orthopaedics. A small number are junior clinical fellows, and some are recently appointed consultants.
1.25.As we have successfully been through a selection process for specialist training, we feel qualified to speak about the advantages and shortcomings of such a process.
1.26.As a committee, we have been involved in the development of the Orthopaedic Curriculum Assessment Programme (OCAP), the Intercollegiate Surgical Curriculum Programme (ISCP) and the Trauma and Orthopaedic Curriculum. We have representation on the JCHST and Specialist Advisory Committees, BMA JDC, Councils of the British Orthopaedic Association, Royal Colleges of Surgery of Edinburgh and England, and as such we feel well placed to offer a trainees perspective from organisations that have contributed in trying to deliver a framework for the implementation of MMC, certainly within the specialty of Trauma and Orthopaedics. Entrance into Specialty Training
1.27.We recognise MTAS and MMC as separate processes and entities. The recent MTAS debacle can only be described as an unmitigated disaster. In our view, it is clear that scant value was placed on advice provided in good faith by many organisations. That this advice was ignored shows the blatant disregard and disdain with which these organisations were regarded by those involved in its imposition.
1.28.It is useful, however to examine how this position was achieved, and to try and understand what positive points can be taken forward from this situation.
1.29.It is clear from the way this was handled that those responsible felt little sympathy for those going through the process, even before it failed. The limits imposed on the number and region of application, and the disregard of family and social support make it clear that those involved had no background in any caring profession, but had been recruited from industry to deliver a product, rather than a person.
1.30.Despite the warning at every stage from our committee, at almost every meeting that we attended, little attention was paid to the obvious flaws in the system. 1.31.The long term effects on junior doctors and the NHS as a result of this are unknown, however to crush the morale of a group of positive young professionals so effectively is nothing less than an outright assault on their psychological welfare.
1.32.It is feared that one of the repercussions of this assaults is to lose some of the most talented junior doctors of a generation. Many individuals have either left the country, or left the profession.
1.33.Throughout the whole of this episode, no one has taken responsibility. There was no clear leadership from the then Secretary of State for Health. Decisions appeared and disappeared within hours. A constant state of flux, that could have been amusing had it been was fictional it was awful beyond belief. PMETB appeared to think it could absolve itself by publishing a statement on its website. The Royal Colleges who previously felt they were stakeholders in MMC, now found themselves isolated. A small number of key personalities would pass information around. Dissemination of information was timed to be received at the end of the working week thus not allowing time for the recipients to react or clarify the content.
1.34.We feel that the following people played a key part in the whole of the failed process: Sir Liam Donaldson, Lord Hunt, Professor Elisabeth Paice, Professor Shelley Heard, Professor Carole Black and Ms Patricia Hewitt MP. The individuals who have not resigned or moved on should do so with immediate effect, and none should have any further involvement with any medical training process forthwith. Their performance in the whole debacle has demonstrated their complete ineptitude at controlling the process, the lack of governance, and an inability to provide leadership that is required with such responsibility or blatant disregard for their role in working with the profession.
1.35.Any revised process should be developed with more than the present cynical lip-service towards clinician involvement. 1.36.There should be no restriction on the number of regions, specialties, or occasions of applications.
1.37.Person specifications should define the minimum and maximum entry criteria for each stage of specialty training.
1.38.Entrance should be on the basis of merit and achievement. There should be clear minimum entry criteria, and these should include a test of surgical theory, clinical knowledge, clinical ability, sound judgement, good communication skills and appropriate language skills. These should be tested in a standardised fashion, and possibly independent from the short listing process.
1.39.The short listing process should be performed using a full portfolio. This should include a CV, and evidence of clinical and non-clinical skills, research and other abilities relevant to the specialties applies for.
1.40.We have no objection to the use of a centralised computer based system as a repository for the information to be collected and submitted. The system must be secure, and able to cope with the number of candidates. It must work.
1.41.We also have no objection to the use of a standardised application form, provided this is used as a part of the short listing process, in conjunction with the evidence cited above, as well as the opportunity to submit other evidence in support of an application, such as publications, and evidence of other experience gained. Application forms must be designed to measure factual information, rather than subjective information. Subjective measures can be assessed at interview. 1.42.A single annual intake of trainees is also acceptable, but in addition, further ranking of unsuccessful, but appointable trainees should be performed. These trainees should be considered for the subsequent year of appointments, and in the meantime, should form a cohort of “LAT” type candidates who can take up posts over the next year to fill in gaps left by OOPE, maternity and other long term vacancies.
Specialty Training
2.The early years of surgical training should include experience in the generality of surgery, to be examined by a test of knowledge and clinical skills in order to progress through training.
2.1.Trainees should get defined experience of allied specialties. It is useful to gain a broad based experience, but spending prolonged periods of time gaining experience that will not be relevant for future practice should be discouraged.
2.2.There should be a degree of flexibility in the system to allow for transfer of appropriate skills between specialties. We appreciate that the emphasis of training a particular specialty may place more focus on differing skills, so that transfer to an equivalent level of training may not be possible, and that some time may need spent gathering competencies at a more junior level before proceeding.
2.3.We support the defined curriculum document: “Specialty Training in Trauma and Orthopaedics”. We also expect the years 7 and 8 curricula to be similarly defined in due course. We would also wish there to be more of an emphasis on subspecialty training during these final years. In addition, it is clear that certain trainees may require longer training if a reduction in hours leads to a reduction in training. This opportunity should be offered to the trainee without penalty. Also, it may be useful to include certain interface specialties some leeway in the length of training beyond year 8, in order to gain further competencies to enable them to achieve an appropriate experience level to progress to “fellowship” level training.
2.4.Progression throughout the training period should be on the basis of striving for excellence. Competencies have been defined by the curriculum. These are a minimum level of achievement expected of trainees. There must be robust mechanisms of preventing progression of trainees whose performance remains unsatisfactory despite targeted training.
2.5.Trainers need to be provided with adequate resources in terms of funding, training, and time in order to deliver appropriate training, especially in the present climate of target driven reform.
2.6.Trainees should be rewarded for striving towards excellence rather than penalised for failing competencies.
2.7.Given that the health service is now in surplus, we would move that these profits be ploughed back into training, and that more resources for training are made available to all.
Exit from Specialty Training, and subsequent employment
3.The ephemeral notion of a consultant physician or surgeon must be clearly defined.
4.Specialty training schemes must deliver training with this definition as the end point of their training scheme.
5.A test of knowledge, clinical ability and communication skills should be used to define the achievement of such a level of training. We feel that the present FRCS (T&O) satisfies these criteria.
6.Irrespective of the view of the present PMETB, we feel that a consultant post should only be available to candidates who have passed examinations in the generality of surgery, completed an approved training scheme, and passed an exit examination in that specialty. In addition, consultants must be capable of functioning independently within their chosen field (as defined by the relevant SAC) in the generality of that field and also have a good understanding of the entirety of medicine and surgery. They are capable of training others within their specialist field and have evidence of an ability to do so. They have a good understanding of the organisational aspects of their practice and play an active role in the governance and improvement of their practice. They may or may not have a subspecialist interest. They may or may not play an active part in research.
7.The present PMETB is an organisation that lacks any reason for its existence. It has succeeded only in reducing the quality of training so far, and introduced nothing but hurdles in trainees’ quests for excellence. It has replaced SAC visits with a poor substitute of visits by its own department, which lacks any experience of the actual specialty that they are trying to assess. The result is a complete fiasco. It has also reduced the ability of trainees to obtain further Out of Programme Experience in order to learn new skills, and placed an enormous amount of bureaucratic red tape in a system that previously worked well and efficiently. This organisation must evolve, or be disbanded. It has been given unreasonable powers beyond its abilities.
8.The government must define its vision of the future of healthcare. Without this, it is impossible to plan for its delivery.
9.At present the health service is delivered mainly by doctors-in-training and middle grades, who are less accomplished than consultants, but none the less provide approximation to adequate service.
10.In section 8.14 of its 2000 NHS plan promised the delivery of the required number of consultants as determined by workforce planning.
11.We believe that healthcare is best delivered by consultants, as defined above, rather than those in training.
12.In order to achieve this, there needs to be a transient but significant expansion in the numbers of consultants. After such an initial expansion only a small number of trainees would be needed to occupy posts vacated by retirement, feminization of the workforce, consultant mortality, and natural attrition.
13.The government must define its vision of the future of healthcare. Without this, it is impossible to plan for its delivery. This lack of transparency in the planning means that training cannot be optimally targeted. This has the obvious repercussion of the wastage of public funds. At present this has not been done.
14.We welcome any needed increases in training numbers provided they are necessary to delivery a consultant led service within the NHS and not ISTC or independent providers.
We would also suggest that the government details the funding required for the employment of these consultants. As this expansion in training posts is likely to be a temporary one. We suggest that funding for the training post be carried over to fund the consultant posts afterward. The funding need not be tied to the training number itself- each trainee should be allowed to be appointed in open competition. This would go some way in restoring the faith that whole tranches of the profession have lost in the government.
15.In the absence of clear funding routes, we support no expansion of training posts until the opportunities for employment have been made clear.
16.It is fallacious to think of medical employment in the UK as a free market. The NHS is a monopoly employer, and as such small variations in the supply and demand of employees are magnified to epic problems, with the mismanagement of large amounts of public funds. The creation of a boom and bust rollercoaster due to a vast oversupply is as useless in the health service as the national economy. It is much better to commission willing trainees to become the consultants that the heath service needs.
17.Employment opportunities at the end of training must be advertised widely in order to obtain the best applicants for the post. All posts within all UK hospitals should be available for UK trained applicants to apply, without exception, as these candidates will have been trained to provide the service that is required.
18.Those trained within specialty training schemes in other countries should demonstrate an appropriate level of experience and achievement, in line with consultants trained in this country in order to be appointable to a consultant post. Appointment to service or career grade (non-consultant) posts need not carry this restriction.
19.New consultants require support and pastoral help from their senior colleagues. This should also be factored in when job-plans for more experienced consultants are being constructed. This does not mean that newly appointed consultants are less able than their more experienced colleagues. In fact they may actually bring many new skills to a department. Neither group should be penalised for providing these services, especially as the newly appointed consultants will one day take on the role of mentor themselves.
20.In order to increase consultant posts with limited funding, we would encourage the use of the European Working Time Directive for consultant hours. Provision for consultants to choose to work longer hours should there be a demand within the service should be possible, but totally voluntary. We envisage this as an attractive option for most consultants.
21.All additionality clauses should be removed from ICATS and ISTC appointments, and these posts should be advertised in the BMJ and NHSJobs. These posts should be advertised for a minimum of seven days, and the closing date should be at least two weeks after the last publication of the advert.
22.Consultants should be allowed to work in ISTCs and ICATS, and also to provide emergency care to the NHS. This may provide a framework for the provision of pastoral care, while maintaining the expansion of the consultant workforce.
Summary
23.Greater clarity, leadership and direction are required to take the present situation forward, with special attention to the governance structure of the organisations empowered with its delivery.
24.Faith in the delivery of training needs to be restored among health professionals and patients.
25.Excellence rather than competence should be the aim of all training programmes.
26.Adequate resources should be provided to trainees and trainers in order to attain excellence.
27.All opportunities to apply this excellence for the benefit of the UK patient population should be available to all UK trainees. Contact Us
28.This report was co-authored by the President of BOTA, Mr Almas Khan, and the committee.
29.We can all be contacted via the website, www.bota.org.uk , and clicking on the committee button on the first page. We can also be contacted via the British Orthopaedic Association (address as letterhead).
