Posts Tagged ‘MMC’

Specialist training should offer more flexibility

By Mike Broad - 7th July 2010 9:10 pm

Specialist medical training programmes should retain some flexibility to help trainee doctors make the right career choices, a study claims.

Researchers from the University of Oxford set out to compare doctors’ early career choices with their eventual career destinations.

They compared the extent to which doctors’ choices of specialties at one, three, and five years after graduation corresponded to career destinations 10 years after graduation.

They found that, 10 years after graduating, almost half of doctors were working in a specialty different from the one chosen in their first year after graduation and about a quarter were working in a specialty different from their year three choice.

The study, on bmj.com, also suggests that changes to postgraduate medical training mean that junior doctors are making their career choices sooner than in the past.

This concern was first highlighted by the Tooke report in 2008, which suggested that medical education and Modernising Medical Careers encourages foundation trainees to make career choices when many are not ready to make such commitments.

Some respondents commented about an increasing lack of flexibility, as they saw it, in applying for specialty training, while some expressed concerns about having only one lifetime opportunity to succeed in getting on to a training programme for their chosen specialty.

The authors conclude that a two point entry to specialty training programmes would alleviate this problem by allowing those who have made early, definite choices to progress quickly into their chosen specialty, while recognising the need for flexibility for those who choose later.

Commenting on the research, Jeremy Brown, a senior lecturer at Edge Hill University in Lancashire, said: “Specialty programmes need to identify ways of supporting those trainees who need time and experience in the postgraduate setting to make a firm commitment that will match their eventual career destination.”

Read the full study.

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Quality compromised in pursuit of cheap volume

By Dr Tom Goodfellow, consultant radiologist - 27th July 2009 1:15 pm

Now I am not one to moan and I know that the most dangerous place in a hospital is reputed to be the door to the X-ray department at 5.00pm (you may get run over by the rush of radiologists leaving)!

But I had noticed that my work load seemed to be steadily rising despite my best attempts to prevent it.

So we decided to review the radiology work load figures for the last three years and the increases were quite unbelievable. CT had increased by 61%, ultrasound by 71% and MRI by a staggering 101% (and I am talking thousands of scans, not hundreds). This huge rise in demand for imaging investigations is reflected nationally, but I suspect we are at the extreme end of the curve.

The reasons for this surge are fairly straightforward. Firstly, we have abolished significant waits for investigations, an achievement for which we are justifiably proud. But this has effectively taken the lid off Pandora’s box - long waiting times were an efficient means of controlling demand.

Secondly, the combined effect of MMC and the WTD has resulted in junior doctors with far less experience and confidence than in former times. Consequently they have a much lower threshold for requesting imaging investigations. This is not a criticism, merely a statement of fact.

Thirdly, public expectations of what the health service can deliver continue to be inflated by politicians. I am reminded of a headline in the Daily Garbage some time ago: “Death rates continue to fall”!

It is true that a significant number of these requests are utterly inappropriate. Earlier today I scanned the kidneys of a frail confused elderly lady with deteriorating renal function. My report stated: “Bilateral 91-year-old kidneys”. We then shipped her off to have a CT scan of her brain (same age). I am not ageist and believe that appropriate investigations should be done at any age, but it’s difficult to know how the results would have altered her management.

You would expect that the response of the trust management would be to rapidly recruit additional general radiologists to deal with the increasing work load. Did they heck! We calculated the shortfall as between eight and 12 WTE consultants. Eight months after we raised our concerns they offered us four, then immediately reduced to three.

It is not as if we are not earning the cash. Last year, based on tariff, we brought in about £20m of business. However our actual annual budget is about £7.5m and we are expected to make a 5% cost improvement this year. We must be the most cost-efficient department in the whole hospital. Yet where has the cash gone? To support the most inefficient parts of the service who still fail to hit the targets despite having millions thrown at them (I mention no names).

So a pretty depressing story. We have managed the work load by ditching the easy things like IP reporting (perversely usually the sickest patients) and by generally reducing the quality of the work we do. Sadly this has resulted in clinical errors, some serious. The clinical governance issues do not need to be spelled out.

Our trust is travelling down the road towards foundation status, yet sadly it seems that nothing has been learned from the Mid Staffs debacle.

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Call for doctors to attend court hearing on GMC

By Mike Broad - 5th July 2009 2:09 pm

Pressure group Remedy UK is calling on doctors to attend a hearing in the High Court as part of its legal case against the GMC.

Remedy’s application for a judicial review into the GMC’s refusal to hold an enquiry into the fitness to practise of the doctors responsible for the Modernising Medical Careers and MTAS disasters will be subject to a hearing in the High Court on 27 July.

The hearing, which should take two hours, will enable the court to determine whether Remedy has a viable case.

Lindsay Cooke, co-chair of Remedy, said: “There is strong case law on our side and our legal team believe we can win.

“Those of you who attended the 2007 judicial review hearing will know how important it was to see so many doctors and their families there. It provides the court with tangible evidence of your concern about the issue and support for Remedy’s application. So we’re asking you, please, if you possibly can, be there.”

If Remedy succeeds in getting permission then it can go on to a substantive hearing of the case. Remedy raised over £20,000 - largely through donations from doctors - to seek a judicial review of the GMC decision. The first judge involved refused permission, so Remedy applied for an oral hearing on the issue.

Due to Remedy’s limited financial resources, the case can also only be taken forward if legal costs are capped, which is within the power of the court.  

Remedy is asking doctors to let them know if they are going to attend by emailing office@remedyuk.org. Doctors can also request a poster from Remedy to advertise the hearing in their hospital.

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Junior doctors’ contract to be reviewed

By Francesca Robinson - 17th June 2009 9:37 am

A review of the junior doctor contract has been announced by the Department of Health.

It is widely agreed that the New Deal contract introduced in 2000 no longer reflects the working lives of juniors following the introduction of Modernising Medical Careers and the staged implementation of the European Working Time Directive.

Pressure group Remedy UK is calling for juniors to be employed on a single contract for the duration of their training programme. A system of having a single, lead employer has already been successfully adopted in a few programmes, it says.

Dr Richard Marks, head of policy at Remedy, claimed the current process of having separate contracts with individual trusts on each leg of the rotation creates problems for doctors applying for mortgages or credit, arranging maternity leave or out-of-programme time, maintaining pension contributions or managing sick leave and disciplinary matters. It also results in greater scope for mistakes on tax codes and seniority levels and repeated pre-employment checks.

Remedy would also like to see the corporate status of deaneries more clearly defined. “We believe that they are employment agencies and should be covered by employment agency legislation yet this could preclude them from their educational role,” said Marks.

A third demand is for greater clarity over the DoH’s Gold Guide, which describes the arrangements for postgrade medical training in the UK. Marks questioned whether this is a ‘guide’ to postgraduate specialty training or an integral part of juniors’ terms and conditions of employment. “Opinions on this change from day to day,” he said. 

Remedy also insists that a new contract should reflect the individual opt-out of the Working Time Directive especially in the craft specialties.

Dr Tom Dolphin, vice chair of the BMA Junior Doctors Committee, said the union will be canvassing the views of juniors about what they would like to see in a new contract. ”The old contract was designed to reduce the hours we were working so we can now move on to the other things that our contract should do,” he said.  

JDC chair Dr Andy Thornley pointed out that the DoH has only announced a ‘scoping study’ of the effectiveness of the existing contract and has not yet given NHS Employers and the other UK health departments a remit to start negotiations with the BMA.

But he said: “We need a contract that is fit for the NHS that we all work in today and I very much hope that this announcement signals the first step on the road to a new contract, something which the JDC has been calling for since 2004.”

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More consultants not fewer or watered down ones

By Dr Jonathan Fielden, BMA's consultant committee chair - 8th June 2009 9:59 pm

We’ve led the teams that have cut waiting times and mortality rates. We teach and train new doctors and we develop the research base that is the lifeblood of UK healthcare. We’re leaders, innovators and we’re fighting daily to provide excellent care to our patients. Underpinned by the CCT and the national contract, the day to day work of consultants is the foundation of high quality NHS care.

The BMA has led moves to promote the concept of consultant-based care. In this model, a development from consultant-led care, consultants are involved in all major decisions affecting patient care, and undertake a significant proportion of the treatment of patients, as appropriate to their skills. This concept is now gaining wide-spread support, as is our call for focused consultant expansion.

However, in recent years the safeguards on consultant-based service have come under repeated attack, sometimes overtly, sometimes more insidiously. The initial MMC blueprint suggested the Department of Health (DH) was interested in creating ‘accredited specialists’ - a post-CCT, non-consultant role, something the BMA robustly fought.

In the wake of the catastrophic implementation of MMC, we then saw proposals for Post-CCT fellowships, which again threatened to quietly usher in a sub-consultant grade, despite a lack of workforce need, and in face of the fact that it could have amounted to a career cul-de-sac for many. Once again the BMA fought to limit these to only those areas where the training need was clear.

While such schemes have not been allowed to take root, I believe new threats to consultant-based care are likely to appear on the horizon. There are two reasons for this, one financial, one political. In the current economic climate, with the NHS being required to achieve billions of pounds worth of efficiency savings, consultants are already being targeted. Misleading editorials about our pay are starting to appear and the right-wing think tank Reform has called for 10% salary cuts.

Yet the idea that a subconsultant grade would save the NHS money does not stand up to scrutiny. Post-CCT posts, whatever form they may take, will by definition need to be taken up by doctors who have undergone lengthy training and will come in at, or close to, the base consultant pay scale. The closest current examples have been in some of the ISTCs, which have needed to offer inflated salaries to attract consultant equivalents.

More importantly, cutting back on quality will not improve efficiency - giving patients the highest possible standards of care now will save money in future. There are multiple examples of how consultants add to the efficiency, safety and value for money of service delivery; let alone of the benefits we provide leading and managing the service. We should look at better opportunities to save the taxpayer money, not least the costly marketisation agenda, PFIs and under-performing ISTCs.

The other threat to eroding the ethos of the consultant-based service is the potential move to locally negotiated contracts. We are starting to see isolated examples of advisory appointment committees being sidestepped, and more importantly hospitals advertising jobs with inadequate numbers of SPAs for new entrants. These are insidious erosions of the quality of consultant jobs. A foundation trust in Stockport recently recruited two doctors to resident on-call consultant posts in O&G - posts which did not have royal college approval, and which provided fewer than the 2.5 SPAs recommended in the contract. This happened because the trust’s foundation status meant it did not have to go through an advisory appointments committee.

Our concern is that this moves us another step away from an existing appointments process, with its national overview, and the principle of an NHS with the same standards anywhere in the country.

We shouldn’t allow any watering down of what trainees can expect from their futures and we should be looking to allow more, not fewer, of them to pursue careers as consultants. This isn’t just BMA protectionism - there is a vast amount of clinical evidence in favour of focused and planned expansion in the number of consultants. This is not idealistic; putting high quality care - driven by a consultant-based service - at the heart of a high quality service is what our patients deserve.

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How to become a flexible trainee

By Mike Broad - 27th May 2009 5:01 pm

Flexible trainees are part-time doctors in training. Flexible training provisions have been in existence in the NHS since 1969. But, impetus to improve access to flexible training only developed in the late 1990s, with new attitudes to work-life balance and introduction of the Part-Time Workers regulations in 2000.

Flexible training is seen as a way to recruit, retain and motivate doctors, who might otherwise quit the NHS because of other commitments. It’s particularly relevant to the medical profession because of the rising proportion of female trainees, who may want to have children, and the high staffing levels required to comply with the Working Time Directive. However, research by PMETB shows that demand for flexible training continues to be largely unmet.

Historical problems with becoming a flexible trainee

Trusts have perceived flexible trainees as expensive to employ. Pre-2005, a part-time doctor (doing out-of-hours work) was paid a full-time basic salary and an additional supplement of 5% or 25%.
Although slot shares increased, many flexible posts were supernumerary, making their employment more expensive still. Extra funding from the Department of Health was made available to help fund flexible training but expired in April 2004. In addition to cost issues, the flexible training scheme was administered differently from deanery to deanery, with inconsistent approaches and attitudes. 

Revised arrangements for flexible training

In 2005, revised arrangements were introduced to improve access to flexible training and make the roles more affordable for employers. These arrangements were outlined in two documents Principles underpinning the new arrangements for flexible training and Equitable pay for flexible training. The guiding principles were to retain doctors who are unable to train on a full-time basis; to promote work-life balance for doctors; to ensure training on a time equivalence (pro-rata) basis; and maintain a balance between educational requirements and service delivery in the reduced hours.

Flexible trainees now receive basic pay and a supplement for out-of-hours work. Basic salary is determined by the actual hours worked and the supplement is paid as a proportion of the calculated basic salary. Band FA attracts a 50% supplement, FB attracts 40% and FC attracts 20%. Flexible trainees who do no out-of-hours work do not receive a supplement.

The revised pay system brought hourly rates of pay in line with that of full-time trainees. And an independent appeals mechanism was introduced for cases where an application was rejected. The Department of Health in England agreed an additional £7million in recurrent funding to ensure its success.

Flexible training criteria

Trainees are required to undertake at least 50% of a normal working week. Day time working, on call and out-of-hours duties should be undertaken on a pro rata basis equivalent to full time trainees in the same specialty, provided they can do so. Trainees are normally expected to move between posts within rotations on the same basis as full time trainees but not necessarily at the same time. When full time trainees normally have an out-of-hours commitment, a flexible trainee will only be entitled to train without completing the out-of-hours commitment for a maximum period of six months subject to educational approval.

There are different ways of structuring flexible trainee roles. Slot sharing is where two flexible trainees are employed and paid as individuals (often for 60% or more) and work together. They share one place on a rota but not a contract and may overlap sessions. Job sharing is when two trainees share a full time post salary, work half the hours and receive 50% of the training opportunities. Then there are supernumerary posts that are additional to the normal complement of trainees on a rota. Sometimes trusts use a less than full-time trainee in a full-time role to avoid the additional expense of a supernumerary role. They typically work four rather than five days a week.

More information on flexible training.

Who is eligible to apply for flexible training?

While all doctors are theoretically eligible to apply, deaneries are prioritising two categories; the first, and most prescient, includes doctors in training with a disability or ill health, or responsibility for caring for children or an ill or disabled partner or relative.

The second category includes those doctors in training with unique opportunities for their own personal or professional development, such as representing their country in sport, or a short-term extraordinary responsibility, such as a national committee.

Religious commitments will also be considered and non-medical professional development, such as management or law courses. Other reasons may be considered but it would be dependent on the particular situation and the needs of the specialty.

How does a junior doctor apply to become a flexible trainee?

The trainee should seek advice on eligibility for flexible training in a meeting with the postgraduate deanery representative. If the trainee is not already working within the grade and specialty, appointment through open competition will be necessary. Potential applicants who do not discuss with the associate postgraduate dean their intention to train flexibly in advance of application to a post will find that funding is unlikely to be immediately available.

The trainee will need to agree a training programme with the deanery. Time for protected study and research should be included within a normal working week.

The regional specialty education committee or programme director will approve the training programme on behalf of the postgraduate dean and the appropriate Royal College. This approval should take no longer than six weeks to obtain. Approval will be given initially for one year subject to annual review.

Approval of the deanery and the employing trust will be necessary for funding of the post. As the recurrent funding available is limited, applicants considering flexible training should apply as early as possible and at least three months in advance of anticipated need.

Once all approvals have been obtained, the start date will be confirmed with the trainee, and the NHS trust requested to issue a contract.

More details

Case studies

Low availability of flexible training

The number of flexible trainees remains low. There are approximately 2,100 currently in the NHS, which represents around 6%. In 2005, the revised arrangements were anticipated to enable 20% of junior doctors to train flexibly by 2010. The Chief Medical Officer’s 2007 Annual Report called for more flexible training opportunities, as did the PMETB Survey of Trainees in 2007. It shows that 22% of female trainees would like to train flexibly but are not doing so currently.

Funding for flexible training currently comes partly from the trust where the doctor works and partly from the budget of the postgraduate medical deaneries. However, the proportion the trust pays is significantly higher than under the old arrangements. The BMA claims that many Category 1 doctors – those with a disability or ill health or caring responsibilities – are still being prevented access to flexible training. They continue to campaign on the issue.

More information:

Medical Careers

MMC

Flexible Careers Scheme

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MMC reasoning reveals need for new leadership

By Lindsay Cooke, co-chair of Remedy - 25th May 2009 10:53 am

Remedy has been handed the outcome of a Freedom of Information request made by a junior doctor in January 2007, just as MMC/MTAS was about to go thermo-nuclear.

Disclosure was furiously resisted by the DoH and reading the email exchange - which is detailed on the Remedy website - one can see why.

They reveal that MMC had as little to do with improving doctor training and patient care as I have with lap-dancing.

It was a dumbing down exercise designed to impose a job culture on a profession, flush out some of the ‘awkward squad’ (senior SHOs who might not be sufficiently biddable for the government’s taste) and - and what an ‘and’ - open the door to a sub consultant grade which would ultimately allow for the culling through natural wastage of potentially the most vocal and powerful awkward squad of all - consultants. That’s my analysis, by the way, and I write this in a personal capacity. Call me paranoid if you like, but it’s not paranoia if they’re really out to get you.

So, what now? The government has succeeded in replacing an organic, evolutionary training system with something unproven and deeply unpopular.

It would appear that your institutions either colluded or were hoodwinked. The elephant is not just in the room but is monopolising the sofa and has cornered the remote control. You’ve been shafted, and grassroots doctors are catching the flak every day in tick box training, rota gaps, insecurity, general demoralisation - never mind WTD coming over the horizon at a gallop.

I’ve spent enough time with doctors in the last two years to know that you see yourselves as special and different. I think you are too. You’re the best and the brightest, and it should not be beyond you to take a long, hard, collective look at the professional, economic, political and social realities you now face, take a deep breath, scream if you need to, and then start coming up with some positive proposals - if only for the benefit of the poor bloody infantry of this process, the patients. I’m one of them which is why I have the temerity to deliver this ’Mummy lecture’ as my children call it when I go off on one. I’d trust you lot over any politician, and so would over 90% of the population.

Remedy can’t and shouldn’t lead this process - indeed, the only kind of leadership I’ll have any truck with is ‘leadership with’ not ‘leadership over’. It can, however, act as honest broker. Arguably, it’s the only organisation that can as it’s the only organisation untainted by MMC.

The challenge for the profession is whether your ivory tower dwellers or those with their heads buried in the sand will have the humility to accept the invitation - and if they do not, whether a new leadership, of ideas and values, creativity and commitment to a great tradition of public service, will emerge.

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Juniors lack confidence in MMC

By Mike Broad - 21st April 2009 11:57 am

Doctors continue to have little confidence in standards of training and care delivered under Modernising Medical Careers (MMC), a survey by Remedy UK reveals. 

Despite a year passing since the Tooke Report, and two from the MTAS debacle, the overwhelming majority of doctors remain opposed to MMC. Seventy eight percent of 877 doctors claim patient care and postgraduate training is worse now than before MMC. 

“I can’t see a single benefit,” one respondent lamented. “Honestly, I can’t. MMC has managed to achieve the exact opposite of everything it was intended to achieve – poor training, reduced flexibility, a lost tribe of SHOs and a disenchanted workforce.”

Fifteen percent did acknowledge that MMC has positive aspects but with the caveat that implementation was poor. Another respondent summed up many of the comments when they described MMC as: “Good in theory, very bad in practice.”

MMC is clearly having an ongoing impact on doctors’ morale. Just under a quarter of respondents expressed a desire to leave medicine and do a different job, while just over a quarter would not advise someone to take up a career in medicine.

“The job is neither stable nor well paid considering the number of hours worked,” complained another respondent. “Trusts work the system to ensure trainees receive minimum banding. Training is continually restructured in a way which is ill thought out and geared towards saving money. The role of the doctor is displaced by non-medical specialists with narrow and limited responsibility. And the consultant grade, which I have been aiming for, will be radically different by the end of my training and I will undertake it with a fraction of the experience of my predecessors.”

One doctor simply said: “Become a dentist or a lawyer instead.”

While many doctors were negative about MMC, there was a much more positive reaction to being a doctor. It’s still considered a good job, despite the changes. Of the sample, 52% are satisfied in their work against 29% who are dissatisfied. Many will also still recommend it as a career. One respondent commented: “Go for it! Things will get better and it’s got to be better than the City right now…”

But there is a price to pay for becoming a doctor. The survey shows that the average debt on graduation of these respondents was nearly £15,000. Nearly half were still paying off student loads.

There’s no doubt that many doctors remain angry with those responsible for MMC. Sixty four percent of respondents claim MMC has had a detrimental effect on their careers.

One described it as: “A disgraceful and catastrophic episode imposed by deceitful quislings who lied about their real intentions and who betrayed their colleagues and the profession.”

Another said: “It’s positive that I got the job I wanted. But it was a shattering and degrading experience. I’m now very cynical about senior doctors and politicians, and especially senior doctors who are also politicians.”

The Department of Health said sufficient efforts are already made to canvass doctors’ opinions. “The deaneries, colleges and the MMC programme have a range of ways of listening to and taking account of the views of doctors as part of annual planning for recruitment and postgraduate medical education,” said a spokesperson. “The current recruitment process and structure of training is based on feedback from consultation, an online survey of junior doctors and a programme of major discussion events with doctors across the regions that took place last year.”

Lindsay Cooke, co-chair of Remedy UK, wasn’t surprised by the ongoing resentment.

She said: “MMC is a political construct which offends almost every core value today’s doctors possess. It was untried and untested; it compromises individual autonomy and choice; it breaks the apprentice model of experiential learning; and it turns doctors from team member to shift worker.

“Doctors are special people, for sure, but they’re people first. MMC turns them into widgets or cogs in a medicine delivery machine.”

She believes the government needs to conduct a comprehensive survey into doctors’ opinion of MMC.

Remedy is also calling for full implementation of the Tooke Report. A DH spokesperson said: “Many of the changes were in the NHS Next Stage Review and are being taken forward.”

Cooke wants NHS: Medical Education England (MEE) – a new independent body advising the government on education, training and workforce policy – to be strengthened, “with teeth and led by those experienced in medical training would be a good start”.

“Advisory committees such as MEE have significant power and influence,” responded the DH spokesperson. “For example, Ministers have accepted every recommendation made by the MMC England Programme Board. In this way, advisory bodies can directly influence policy decisions. The authority and influence of MEE comes from the quality and clarity of advice that it provides to Ministers.”

Remedy UK Survey

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No easy solutions to WTD so why implement now?

By Mr Matt Jameson Evans, co-chair of Remedy - 19th April 2009 2:27 pm

A bewildered profession is bearing witness to frenzied debate, speculation and disagreement over the implementation of a 48-hour week for juniors on 1 August.

As the seconds tick away towards the deadline, a simple question is left hanging in the air: “Why now?”

Leaving aside the questionable timing, the debate boils down to two fundamental questions:
• Can we be sure that all affected services can cope with a 14% reduction in working time?
• Is the cost of a more palatable trainee lifestyle a consultant body with significantly less experience in the future?

The consequences of a chronically understaffed, stretched service are fresh in the public consciousness; look no further than the recent reports on the Mid-Staffordshire NHS Foundation Trust and the Birmingham Children’s Hospital.

It’s is arguably a brave stance for the Secretary of State Alan Johnson to dig in his heels on the EWTD in light of these events. You hope that the alarm raised by key members of the profession about service shortages in August is ringing around in his head right now.

But the question of training always attracts less media attention. With a cause and effect lead-time of 10 to 15 years the reasons are obvious. It was therefore good to see training raised as a central issue in the March debate on EWTD in Parliament by the shadow health minister.

Not so encouraging was the response from the Secretary of State for Health as to why trainees no longer need exposure to patients. “Developments in new technology such as virtual reality surgical simulators mean that there is increasingly, and thankfully, less need for inexperienced trainee surgeons to practice their skills directly on patients,” he declared.

This cynical abuse of logic was trawled out during the roll out of MMC as the fundamental reason why the progressive reduction of surgical training from 30,000 hours to 6,500 wasn’t going to have an impact on patient care.

It bubbled up from a few scattered developments in training technology (which have almost zero impact on the broad base of current trainees) and was inflated into a concrete fact to prop up policy decisions in the Department of Health.

It should be resisted as an idea at all costs, unless you know more about the advance of technology than I do and have already pre-paid for your ticket to the moon and can guarantee that you won’t be requiring surgery in the UK in 20 years time.

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