HSC into MMC - evidence

NHS Employers submitted written evidence to the Health Select Committee for their inquiry into MMC and MTAS on 16 October 2007. The evidence was based on the views and comments received from employers, including members of the Medical Workforce Forum. The full evidence can be found here.

• Introduction
• Executive Summary
• What are the principles underlying MMC and are they sound?
• To what extent have the practical implementation of MMC been consistent with the programme's underlying principles?
• The strengths and weaknesses of the MTAS process
• What lessons about project management should the Department of Health learn from the failings in the implementation of MMC?
• The extent to which MMC has taken account of the supply and demand of junior doctors and the number of international medical graduates eligible for training in the UK.
• The degree to which current plans for MMC will help to increase the flexibility of the medical workforce
• The roles of the Department of Health, Strategic Health Authorities, the Deaneries, the Royal Colleges and the Postgraduate Medical Education and Training Board in designing and implementing MMC.

Introduction

NHS Employers is the employers' organisation for the NHS. Part of the NHS Confederation, we provide support and representation to employers in England.

We welcome the opportunity to provide evidence to the Health Select Committee and will be happy to provide any further information to the Committee as the inquiry progresses.

We believe it is essential to have employer input into decisions being taken on changes to medical training and to provide employers with support and information in order to realise the benefits of MMC for both the profession and the service.

Getting the right doctors in the right jobs for the benefit of both patients and the profession is a priority for employers, and NHS Employers endeavours to play a full part in achieving that objective.

We have worked closely with national stakeholders and employers to help resolve some of the well-publicised problems which arose during the first recruitment to speciality training under MMC and especially with the new electronic recruitment process (MTAS). We have hosted a number of meetings on MMC over the past 12 months, had regular discussions with our Medical Workforce Forum and communicated extensively directly with NHS organisations to gather views and share information.

We had a seat on the Douglas Review and now have two representatives on the MMC Programme Board (England). Overall we feel we are well placed to give a balanced service view on MMC and the future training of doctors.

Back to top

Executive Summary

We recognise that recent months have been stressful and difficult for many junior doctors as well as for key service staff in the NHS.

The focus has inevitably been on specialty recruitment but looking forward it is important to take a wider view of MMC. There is much that is good about MMC, despite the obvious difficulties that have emerged during the speciality recruitment process and it is important to look constructively at what needs to be learned in order to ensure the highest quality patient care as well as providing satisfying careers for entrants to medicine into the future.

We would also like to draw attention to the huge commitment and effort that has been put in by many to resolve the problems that have arisen in 2007. All indications are that trainees appointed to specialty programmes this year are of excellent calibre.

More flexibility, more involvement of employers in planning and more testing of new ideas are key, but we have cautioned strongly against further radical reforms in 2008, and were pleased to see health ministers agreeing to return to locally-based, deanery-led recruitment for specialty training next year.

Ensuring flexibility for doctors in training while achieving an effective balance between service needs and workforce planning is essential. This can only be achieved with strong engagement with employing organisations. It is vital to support a recruitment and selection scheme which gets the right people in the right training posts to produce the best qualified doctors for the future NHS.

The requirement for senior level HR support to MMC and effective employer involvement needs to be addressed. NHS Employers provided intensive advice and support to the DH throughout the period of the Douglas review. However, while representing the view of NHS organisations and their service needs at a national level, we are one of a number of stakeholder organisations.

We recognise that while the MMC project itself was under-resourced, the consequences of the problems resulted in very significant costs for the NHS.

We will gather the views of employers on the recommendations contained in the Tooke MMC report Aspiring for Excellence published on 8 October. We welcome much of Sir John's report and believe that, despite the difficulties experienced by doctors and employers over the last 12 months, many of the lessons learnt have been taken on board in his proposals.

His conclusions reflect many of the views expressed in our written and oral evidence to his inquiry and in a position paper on the future of the medical workforce published by NHS Employers on 9 October 2007.

In particular we welcome his suggestions of greater flexibility in training, the need to recognise the service contribution of doctors in training and the importance of improving medical workforce planning at both national and local level. We are also encouraged by his acknowledgement that there needs to be greater employer and service input into planning and governance of medical training.

Back to top

What are the principles underlying MMC and are they sound?

Trusts are generally very supportive of the broad principles of MMC. Structured training based on quality-assured national curricula with progress measured by the acquisition of competencies is broadly seen as the right way forward.

We believe that the introduction of MTAS caused many to lose sight of these principles as emphasis switched to navigating the complex recruitment process rather than what MMC set out to achieve.

As employers have gained a greater understanding of the full implications of the MMC training system and the recruitment cycle developed to support it, it has become apparent that a number of strands in the MMC policy needed more thorough thought and testing. While the underlying principles of MMC remain sound, having now experienced the first year of recruitment we believe that adaptations are needed to introduce greater flexibility during training.

Additionally, further discussions need to take place between employers and representatives of the medical profession about the future role of the CCT-holder whose training experience will be shorter under the MMC curricula.

NHS Employers has already engaged in these discussions, and will now refine these in the light of the Tooke recommendations for lengthening and changing the structure of training. In particular the concepts of core and higher training followed by a period of practise in the role of 'specialist' as distinct from that of consultant. The trust registrar grade should be made an attractive and viable option for many doctors who do not progress to higher training. Implementation of the Staff and Associate Specialist contract, negotiated between the BMA and NHS Employers, will be a key factor.

Back to top

To what extent have the practical implementation of MMC been consistent with the programme's underlying principles?

Employers have the same aim as the medical profession in ensuring that the best candidates are short listed and appointed to training places and that staff are treated fairly.

Patients deserve the best doctors with the highest quality training and there is no doubt the old system of training needed reform. In retrospect it is easy to see that some things could have been done differently. Clarity of objectives and governance, longer lead-in times, wider testing of some elements and better communications would all have made a difference.

However, it is worth noting that many aspects of recruitment to the Foundation Programme and to general practice worked well. Employers report that they have appointed excellent specialty trainees and that those doctors selected in Round 1 were generally of very high calibre. However, the longer term effect on the morale of doctors is yet to be assessed.

Anecdotal evidence suggests that selectors felt the selection process through a national online application form could not fully distinguish the best candidates. It was generally felt that the process lacked flexibility and that once candidates had been accepted to run-through programmes, they would be unable or reluctant to reconsider their specialty choice.

There was a general lack of understanding of the role and purpose of the fixed term (FTSTA) training option, and how that fitted the underlying principles. It was seen as a second-rate career path, unpopular and hard to fill.

As part of a more 'career ladder' approach to employment and training advocated by employers, it is possible that the NHS will seek to employ fully-trained CCT holders in a different role to that of consultant. Such a role could provide an alternative career pathway for trained doctors not wishing to seek consultant posts and ensure that patients are being treated by trained doctors.

Initial discussions indicate that employers welcome the Tooke report recommendation that defines the role of the specialist and the further learning and assessment required to be eligible for consultant posts. However we need to explore the implications of these recommendations in more detail with employers before submitting our full response to the MMC Inquiry panel.

Back to top

The strengths and weaknesses of the MTAS process

Trusts are firmly of the view that electronic recruitment is the right way ahead for a modern NHS, reducing paperwork and administrative functions, and releasing resources. We have promoted use of NHS Jobs, the online recruitment service, as a cost-effective tool for advertising posts in the NHS.

We should add that MTAS worked very well for foundation programme applications with the vast majority of applicants being offered first choice postings, and with deadlines being met.

However, employers' experience of the far more complex rules and processes for specialty training devised for 2007 under MTAS was less positive. The process was felt to be rushed and decisions made (or reversed) too quickly to test the impact or assess likely risks.

NHS Employers made frequent calls for senior dedicated HR support to be provided for MMC transition. We believe the absence of that support has led to failings in recruitment design at both policy and implementation level.

This was also the first year of the process and the transition cohort was significantly bigger than it will be in future years. With no previous years' experience to draw on, doctors were also understandably nervous about the process. The key reported problems were:

Shortcomings in longlisting were widely acknowledged, particularly in larger deaneries where there was a particularly high volume of applications, especially over the final weekend before the closure of Round 1. Two deaneries which failed to implement agreed processes correctly led to inconsistencies in shortlisting and longlisting. The delay to MTAS functionality to support the shortlisting process caused handling backlogs and a serious loss of confidence. This was caused by a major change in Unit of Application design in one deanery in the final weekend before the system went live.

There was doubt in some areas over whether all shortlisters were well enough trained in both the new competency-based selection processes and use of the MTAS software. Not having sight of an employment history during shortlisting was a mistake.

Some applicants were concerned that they did not have enough guidance in completing the electronic form.

Eligibility criteria were confused and inconsistently applied. The decision to include overseas doctors added many thousands of candidates, increasing both the workload for recruiting deaneries and trusts and concern among doctors (and media) about competition for posts.

The extent, consistency and timeliness of communications to doctors and employers at an early stage and then throughout the process could have been improved.

We believe that over time a national 'fit for purpose' e-recruitment process can be successful in the NHS but this must be preceded by pilots tested over a realistic timescale which allows for software changes to be implemented without major jeopardy to the project as a whole.

Back to top

What lessons about project management should the Department of Health learn from the failings in the implementation of MMC?

Medical recruitment is a specialised area of expertise, and we believe the Department of Health (DH) and the MMC team could have made more effective use of the experience which was available to them from employers. Consultation with service stakeholders began too late in the day. The software requirements or limitations of MTAS were not properly managed and this was further hindered by some very late decisions on recruitment rules.

We felt that risk assessments were not always tracked adequately. There were a number of subgroups working on various elements but little evidence of an overarching national project plan. Governance was spread across a wide range of groups, both in England and UK-wide, and it was unclear who held ultimate responsibility.

It was difficult to identify which areas were priorities, assess progress on changes previously agreed, or who was responsible for driving these forward. There was at times a lack of clarity about the respective roles of the MMC team and the wider DH workforce directorate.

While the MMC website was used to provide updates to junior doctors, engagement with stakeholders and communication with the service was limited. It was because of this that NHS Employers initiated work in this area.

Back to top

The extent to which MMC has taken account of the supply and demand of junior doctors and the number of international medical graduates eligible for training in the UK.

The decision to include overseas doctors in the cohort of applicants for speciality training in 2007 was felt by employers to be the right one at the time. International graduates have valuable skills and some hospitals and specialities rely heavily on them, and patients want to be treated by the best doctors available. That said, applicants for the future need to have a realistic picture of opportunities in the UK. Better modelling on likely applicant numbers was needed for 2007, by entry level and by specialty.

Initial indications from 2007 Round 1 recruitment suggested that 70 per cent of training posts were secured by UK graduates compared with 30 per cent by graduates from EEA and non-EEA medical schools. This ratio is good but not good enough to exclude overseas trained HSMPs from applying for specialty and GP training in the near future. While employers agree that the decision should be based on competency rather than numbers alone, there is support for asking the Home Office to raise the bar on HSMP entry status for doctors as a way of managing applicant numbers in the future. We believe, however that the situation should be kept under review, as over time, this ratio may change.

Back to top

The degree to which current plans for MMC will help to increase the flexibility of the medical workforce

It is critical to match service and employer needs with the need to provide satisfying and meaningful medical careers.

While agreeing in principle with the run-through concept, employers believe there is a need for much greater flexibility than the current model of run-through training provides. Trainees should have the ability to switch between specialties if they feel they have made the wrong choice or to take time out and then return to their specialty. Trusts need transparent processes for dealing with poor performance, enabling them to remove trainees who do not progress from programmes.

There is a strong feeling that committing to a speciality after only two years is too soon, especially if the trainee has had little or no exposure to the speciality in the foundation programme. 'Mini-rotations' or 'taster' sessions during foundation could help with career flexibility.

Many employers feel that some element of competition or 'gateway' based on an improved and robust assessment model at the end of ST2 is preferable, meaning there are effectively two points of entry to speciality training and a new break point prior to ST3. This would ensure that the very best doctors progress to final training, while facilitating alternative career pathway options and enabling doctors to grow and develop at their own rate. However, there is no 'one size fits all' solution and such flexibility may need to be decided on a specialty by specialty basis.

We believe the Tooke inquiry recommendations for the introduction of core and higher specialist training may provide the desired break point at a time in training that is more appropriate than seen previously. However we will need to discuss these options in more detail with employers to assess their full implications.

There is some good careers information available for doctors in training and this year's experiences have given impetus to further developments.

NHS Employers has worked with the MMC team and the medical professional bodies on the development of a new national website NHS Medical Careers. The website will aim to provide consistent information to medical students and foundation programme trainees about the future training and career opportunities available. The website ownership was handed over to DH in October.

Back to top

The roles of the Department of Health, Strategic Health Authorities, the Deaneries, the Royal Colleges and the Postgraduate Medical Education and Training Board in designing and implementing MMC.

It was clear to trusts from the outset of MMC implementation that this major change programme required strong leadership, and good risk management and project management. NHS Employers raised concerns about the lack of effective governance at both the MMC Programme Board and the MTAS Project Board.

We see PMETB's role as central to ensuring that entry standards are maintained. But those standards must also reflect the 'employability' of doctors, making sure we are appointing doctors who are fit for purpose and possess all the necessary clinical skills and experience. PMETB could have been more involved in translating that into the processes of recruitment.

SHAs were in the throes of reconfiguration for much of this period and may have been unable to take full account of the significance of the impact of changes to medical training. With the benefit of hindsight it would have been important to have ensured they took a leadership role early on but probably few fully appreciated the full extent of the change that was about to happen. This was primarily seen as a change in education and the implications for service delivery were not realised by many until late in the day.

SHAs were subsequently expected to take ownership of problems such as guaranteeing employment for displaced doctors. Many found they no longer had the leverage, funding or staffing to ensure such policies could be fully executed.

Deaneries and their supporting trusts did not have the capacity, particularly in dealing with the huge volume of applications. The communication between deaneries and trusts was patchy. Undoubtedly deaneries and employers pulled out all the stops, with many people working excessive hours to make sure the recruitment process was completed. Employers have told us that the goodwill that saw us through this year may not be repeated in the future.

We have covered many of the DH issues already but it is important to stress again that there were a number of individuals who worked tirelessly to try to resolve the problems that arose in 2007. For the future we would emphasise the need for better engagement with key stakeholders and longer term planning.