RemedyUK Welcomes Our First Guest Blogger: Professor Morris Brown.

Last month our campaign group, of 50 professors and presidents of specialist societies, was belatedly baptised – or whatever the politically correct name for naming is! Our name, Fidelio, is taken from a story about one victim of the arbitrary exercise of power, and victory against the odds of oppressed innocence. More loosely knit than RemedyUK, and more intermittently active, we will seek whenever possible to influence senior colleagues whom we perceive to be treading a wrong path. At a time when a conspiracy of silence could not have been more effective than the current apathy – not only among the media and public, but even most of the medical profession – we need to keep telling each other and those most hurt by MMC/MTAS that they are not forgotten. Otherwise we play into our opponents’ hands.

Pressure groups like Fidelio and RemedyUK are unlikely ourselves to achieve justice or solutions. We can hope that the Tooke Review will surprise us with fundamental doubts about the validity of MMC and strong recommendations for righting the wrongs of this year. The latter seems particularly implausible given that its date for reporting is before the official end of round 2 – allowing Tooke (like the Colleges, below) to express optimism that there will be no wrongs after round 2. The BMA has largely disqualified itself as a meaningful voice by its opposition to RemedyUK. Our poll found 80% of junior doctors would like RemedyUK not the BMA to represent them. The new BMA leadership cancelled a scheduled meeting with us last week, and failed to answer requests to speak out against the slippery practices of round 2, and against disqualification of many doctors from continued employment on 1st August.

We believe therefore that the hope and responsibility for a resolution to this year’s crisis resides in the Royal Colleges. If what follows sounds faintly critical, it is only to encourage debate and because this is permitted. The DoH, by contrast, whom some see as our friends, have banned us from participation in their new MMC advisory board – ‘unlike the recently defunct Review Body, this will be a genuine expression of the views of the profession, from whom most members will be drawn’. Free speech is alive and well at the Elephant Castle – freedom, that is, to echo the Minister’s views.

On the 8th June, by when all first-choice job offers should have been made, it became apparent that some 40-45% of doctors were empty-handed. We sent an open letter to the presidents of all the Royal Colleges asking for strong, united action, ‘regardless of red faces in the Department of Health’. Irritated, the presidents replied to the effect that it was too soon to be anxious, that all would be sorted (they hoped) by the 22nd June – or, if not, in round 2. On 22nd June, by when it was apparent from our rolling poll – and leaks from the DoH – that some 40% were still without jobs, and that almost one third offered jobs had been offered only FTSTAs – we published our open letter in the BMJ. About 100 online responses to this, at http://www.bmj.com/cgi/eletters/334/7607/1285#170337, unanimously chided the Colleges for their approach.

A good-humoured response to this by two presidents prompted us to seek a meeting which was held between three of us and about eight presidents (including the Chairman of the now defunct Review Body, but not the PRCSEng) plus the Chairman of AoMRC on 28th June. Although clearly useful in breaking the ice, and generally good-natured, the meeting was depressing in confirming the lack of collective will among the presidents to take any affirmative action that differed substantially from existing DoH policy. We were not there seeking favours for ourselves – Fidelio has no self-interest; rather we were suggesting to the presidents a possible solution to the crisis which the change of government and SoS offered a one-off opportunity to pursue, and in the process redeem the Colleges’ recent reputation (according to the BMJ posts) for submissiveness. Yet one president seemed to think this reputation was Fidelio’s fault!

While Fidelio believes that, in a time of discord between the profession and DoH, there needs to be blue water between us and leaders who clearly speak on behalf of the profession, the Colleges appear to believe the better strategy is to be part of the DoH dialogue behind the scenes. If this strategy were working, we would fully support it. But it isn’t. The results of our poll, published in full at http://www.fidelio.org.uk/index.php?option=com_content&task=view&id=25&Itemid=44, show that round 1 has resulted in a disproportionate failure of the best candidates – assessed by the traditional markers disallowed under MTAS, e.g. 1st class degree, distinction in finals, PhD. We believe this is a consequence of the single interview, and the tradition that the best candidates apply for the best (and therefore most sought after) posts. Many of these will end even round 2 empty-handed, or with a FTSTA at best. As things stand, thousands such doctors face an end to their career in UK medicine. The DoH promised an instant resume of results after round 1. This has not happened. Indeed invidual applicants hear of their failure inhumanely through failure to receive an email.

Our summary of the current problem, and possible solution, is shown below. We will include this in our evidence to Tooke, together with fundamental objections to the inflexible top-down, minimal-competency philosophy of MMC. We have written to the new SoS, and surgeon health-minister, summarising the solution and requesting a meeting. Realistically, however, it needs concerted action by the Colleges for a chance of success.

Meanwhile, round 2 in many areas would come second to car-boot sales in their level of organisation and fairness. ‘Now you see them, now you don’t’ adverts, lack of any of the promised information about numbers and whereabouts of jobs, and continuing lack of CVs or references at interviews, almost makes one nostalgic for the MTAS computer! Is chaos better centralised or served up with a regional flavour?

The presidents of the Colleges are good people. They are affected by individual letters and stories. Indeed they say they prefer private to public pressure. Please write to your president, ask your colleagues to write to their President … and to their colleagues asking them to write etc etc. “The tyranny of a prince in an oligarchy is not so dangerous to the public welfare as the apathy of a citizen in a democracy.” (Montesquieu)


MMC/MTAS 2007: Diagnosis and Treatment

Problems
1. The new system of promotion is a parallel ladder on which the width of each rung is the same as the one below.
a. Therefore the number of ST(n) posts is the same as the number of doctors already appointed to ST(n-1) posts.
b. Therefore there is little or no opportunity for doctors appointed to FTSTA posts to rejoin ST training and gain a CCT.
c. About one third of posts offered in round 1 were FTSTAs, many of these going to very bright doctors (1sts, distinctions, PhDs) who under the old system could expect careers in teaching hospitals or academia
d. These very bright doctors are now effectively excluded from mainstream medicine in the UK
2. Run-through forbids trainees to move to a different part of the country for the rest of their training.
a. For partners in different regions, this is a domestic disaster
b. Because doctors were permitted only one application per specialty in a region (e.g. whole of London and SE), it was much more difficult for partners to obtain posts in the same part of the country than under the old system
c. In Medicine, where entry to run-through is to Core Medical Training without a guaranteed specialty, they will be restricted subsequently to those specialties with vacancies in their region.
d. The opportunity will be lost for a bright doctor to join a specific sub-specialty and/or department pertinent to their field of research, unless that department is in the region of their original run-through appointment
3. If Tooke accepts the recommendation from the RCP (and many others) that run-through is dropped for medical specialties, there will be a one-off cohort of run-through doctors, many unhappy with their apparent windfall


Possible solutions
1. Suspension of run-through for non-shortage specialties.
a. This is the cleanest solution, popular with many of those appointed to RT posts, for the reasons above.
b. However, it is easily dismissed by legal and quasi-moral objections
c. The legal position is untested, since the contracts (most not yet issued) are for 1-2 years with the employing hospital
d. The moral objection – ‘these doctors were promised run-through’ – ignores
i. the competing claims of doctors cheated of any appointment by an unfair (including single-interview) process, and
ii. the asymmetrical distress of
1. doctors deprived of a windfall that will not have existed either before or after, vs.
2. doctors deprived of any future career prospects
e. Suspension of run-through might be seen as analogous to re-appropriation of stolen goods from a 3rd party customer who bought them in good faith

OR

2. A guaranteed level playing field for all eligible doctors applying for ST3 or ST4 posts
a. ‘Eligible’ is likely to mean all ST or FTSTA doctors, but may need to expand to include any doctor who’s CV has been reviewed by an independent appeal board
b. This solution could be restricted to those specialties, e.g. Medicine, Surgery, Anaesthetics, where there is strong evidence of many good candidates not being appointed
c. The guarantee should be made now, and its implementation worked out over the next year
d. Implementation is likely to include one or more of:
i. Temporary expansion of ST3/4 posts in competitive specialties
ii. Raising the barrier of competency testing required for promotion from ST2 to ST3, or ST3 to ST4
iii. In Medicine, restriction of run-through (which is not promised into any particular specialty) to less popular specialties, e.g. geriatrics
e. Expansion of posts in popular specialties is in any case highly desirable in order to accommodate and encourage a floating cohort of numbers used for doctors entering and leaving research
f. The cost of expanding numbers is limited to that of the temporary bulge required to fix this year’s problem – unless, as in (e), the bulge is then found desirable for other reasons.