A patients’ guide to Modernising Medical Careers and MTAS – Part 1

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You can find my most recent commentaries on the Junior Doctors’ crisis as it unfolds in 2008 by following this link.

The crisis facing Junior Doctors in the UK is complicated and heart-wrenching. It is also confusing. Most of the people who write about it are either directly involved and assume a lot of prior knowledge, or they are not directly involved and find it too complicated to understand. It has taken me months to get my own head around it, but I think I have managed that now.

In a nutshell, we have more people whose ambition is to become a consultant than there will be consultants’ posts for them to fill. This blog entry explains how and why we got to that situation. It also explains that instead of encouraging these specialists to remain in the NHS and improve the quality of the Heath Service over all during the next decade or so, (credit then being taken by the next government, presumably the Tories), Blair and Hewitt are forcing the issue now in a way which will result in a huge number of specialists leaving the NHS altogether. It does so without anger but with a lot of sarcasm.

Sit tight, and I’ll do what I can to explain it.

A decade or more ago there was a real shortage of Junior Doctors. It was not an attractive profession at the time. It was expensive to get into, not particularly well paid, and they had to work crazy hours. Putting it crudely, each hour that a consultant works in a hospital generates n number of hours of work for his or her juniors. The NHS saved money on junior doctors by paying them a fixed salary, and then getting a hundred or so hours out of them per week. But the ratio of numbers of consultants to numbers of junior doctors was pretty tight. Yes, there were more junior doctors than consultants, but it wasn’t that many more. It was reasonable for any junior doctor to expect to become a consultant one day, because enough of her peers would become GPs (a very family-friendly form of doctoring) or leave the profession to have incredibly clean and well educated children, or decide that medicine was too messy and leave to work for a pharma company or law, or to become a journalist or comedian instead.

So far, so exploitative.

Then, in the late 1990s, the sainted Blair decreed a solution for this, and did two things. One long term, one short term. The long term solution was to increase the number of medical school places. The short-term solution was to reduce the number of hours junior doctors could work, and invite overseas-trained doctors to come here and help us out.

So far, so visionary.

Now, though, junior doctors are working reasonable hours, (40-60 rather than 80-120), and the home-grown med-school graduates are out on the wards.

Bingo. You’d think.

This of course means that the ratio of Junior Doctors now to Consultancy posts in 15 years’ time is even more fiercely competitive than before. The obvious and sensible thing at this point would be to make it easy for doctors to continue as specialists without going for full consultancy in the same way that teachers can choose to remain subject teachers, to become department heads, or year heads, rather than going for deputy headship or full headship. There is no shame or failure applied to those who decide to continue as full-time teachers rather than going for the glories of the headship. The model is there. The benefit of applying this to the medical profession is that it there would have been a raised level of experience on the wards from doctors who continued as specialists without being shamed by not becoming consultants. The simple way to have achieved this would be to to close the door behind the existing overseas-trained doctors, keep the ones we’ve got, and choke back the tap very slightly on the medical school intake. The bulge of doctors who started on the wards some four or five years ago would progress more slowly in the profession than their older or younger colleagues, but we would keep their accumulated skills and experience.

So far so obvious. But not obvious enough for Tony Blair and Patricia Hubris.

Instead the government has decided to do four things simultaneously.

1) Reduce the amount of time it takes to train to become a consultant. I have no idea what the logic is behind this, but it means of course that there are even more people eligible to be consultants than there were previously.

2) Withdraw the work permits of the overseas doctors. So people who have lived here, working incredibly antisocial hours, supporting our beleaguered NHS, improving the access to health-care in places with a high immigrant population as well as making the numbers up right across the country are suddenly surplus to requirements. Forget the fact that they may be married, have children, have friends and a life here. Ship the scroungers back home! No one’ll miss them.

3) Force the locally trained surplus of young specialists into pre-consultancy roles now, as a single exercise, implemented this year only. Make sure that the numbers are exactly right. Do not put slack into the system to account for the fact that increasing numbers of doctors are women and might appreciate a more family-friendly workload. Do not put slack into the system to account for changes in medical technology which might mean that some specialities needed more consultants than before. Above all, do not give the doctor time to prove whether or not they would make good consultants. Oh no. Make the choice now. Make it once.

4) Discard the waste. Who needs unnecessary doctors, anyway?

This is like looking at a bunch of five year olds in a swimming pool and selecting your national swimming squad for 2017-2027 now. No second chances. No time for re-thinks. No chance to change your mind.

It beggars belief, doesn’t it?

It should be stressed that for doctors who are two, three or more years into their speciality training they have had one chance and one chance only to continue it. For those who were not selected by the MTAS process two weeks ago, their chance to continue as specialists has gone for good. They are explicitly prevented from applying again. The options open to them are to leave the profession, leave the country, or hang around locuming and looking for non-specialist Trust jobs. So, no, they probably won’t be unemployed, but by far the majority will either leave the country or leave the medical profession. Is this really the best use of the time and money they and we have spent getting them so far?

So, if you live in the UK or are a British Citizen abroad, I’d appreciate it if you’d consider how it can possibly be good for the nation’s health to discard a fifth of a single generation of doctors in just one year. If you find it as confusing as I do, then you might like to consider signing the Downing Street petition asking the government to return the control of medical training to the Royal Colleges.

Part 2 looks at the way MTAS forces doctors to relocate at random around the country, uprooting their partners and families in the process.

Part 3 considers the academic research on recuitment and assessment methods and discovers that the Self Assessment Competency Questionaires have been invalidated by the way in which they have been introducted.

Part 4 considers the debt we owe to the overseas-trained doctors and how we are repaying it. With a kick in the teeth, basically.

28 responses to “A patients’ guide to Modernising Medical Careers and MTAS – Part 1

  1. Thanks for clarifying that, Aphra. I’ve been following FtM’ Doctor’s posts, but you make it clear how ridiculous the situation is.

  2. My pleasure Charlotte. I have gone from considering it a crazy way to run a Health Service to deep searing anger about what is being done to the individuals involved and round again to pure white rage at what is being done to all of us who use the NHS.

    I tell you something. I wouldn’t be Patricia Hewitt and ill.

    Do you know, if you are one of her constituents and want to see her, her minders will ask what you do for a living before they ask what it is about. If you work for the NHS she will not see you – even if your problem is with housing, schooling or some other non-NHS related issue. I’ve seen dogshit with more integrity than that.

    No. I wouldn’t be Patricia Hewitt and ill. She might just be worth being struck off for.


  3. My Gawd! That is just the lowest thing!
    I can’t belive how many times I am finding myself disgusted at the current crop of Labour ministers. When the Tories were in power, I was disgusted – a lot. But that was to be expected. When this governement won power back in 1997, I held so much hope. I was on a high for weeks after the victory. And I sooo admired Blair.

    How things change.

    I agree with Charlotte. This is a very informative and clear explanation about the doctors predicament. Thanks Aphra.

  4. There’s more to come, Earthpal. What is being done is bad enough. I’ve come to wish that how it is being done was merely cruel and inefficient. But I’ve discovered from digging around in the research papers on recruitment and assessment methods that the way that the specialists are being assessed is completely invalid. Common sense says it’s crazy. Research shows it’s wrong. I’ll post what I’ve found over the next couple of days or so.

    Thank you for reading Earthpal. Please – spread the word.


  5. I am a junior doc. This is an excellent explanation! Far better than I have been able to explain it to my non-medic family or friends. There is a link to this blog on our doctors forum, which is how I found it. I can almost see how the politicians decided our future now. Well done!

  6. Thank you Alexandra. Good luck. I feel embarrassed talking to junior doctors at the moment from my nice secure position outside the profession. I cannot believe that this country is doing this to you. Some of us do know how much we need you all you know, despite the appalling comments in some of the news papers and blogs.


  7. A really good explanation Aphra.

    Well done.

  8. Thank you for your support. Please feel free to come and join us on our march on 17th March against all this, I’ll be there! Voices like yours need to be heard by the public, as the Government’s insideous hate campaign against doctors in the media means we are now seen as whingeing fat cats!

  9. I’d be there..

    If I wasn’t working nights, and unable to swap it.

  10. Do you know, I just might, even though the one who drew my attention to this is working nights and unable to swap it.


  11. Spot on!
    Await your piece on MTAS and MMC.

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  14. Thank you Kumar, Chosen Flower and FtM Doctor.

    Kumar, post #2 is out now, and #3 is in draft.


  15. Thank you Aphra for a concise breakdown of the problems that we have gone through for the past year, let alone in the past month.

    I am fed up, disillusioned and mightily pissed off at the whole system.

    Please continue what you are doing. You have explained it far better than most of us in the profession could have, another reason why the application forms shouldn’t have been as fluffy as they were.

  16. Great explanation! I too have been trying to work out what’s going on from the outside, and it’s been hard work. Maybe the doctors would like to borrow your version for one of their anti-MMC sites.

    Just a few things to add:-

    – there was some upside to the horrendous hours that the juniors used to work; they used at least to come out the other end with excellent practical experience. Now, this is much harder, and many of them are fudging their timesheets. There are plenty of juniors arounf worying about their lack of practical experience, it’s not just the old fogeys going “in my day…..”. Hard to know what to do about this apart from extend training. Of course this plus the shorter training means that the consultants of the future will have the same name but be very much less experienced, and probably therefore much narrower specialists. I think this may have been part of the reason for shortening the training; to turn consultants, effectively, into technicians in a very specific area of medicine.
    – Blair’s desire to shorten their hours was not his own kind thought, it was driven by the EU Working Time Directive ie the EU said he had to.

  17. Ioimy, it’s not just a pleasure, I see it as a political and moral duty. By the time the UK wakes up to the fact that the guts have been ripped out of the NHS again you guys will be putting your kids through Australian schools and thinking “thank god for that”. But it’ll be years before it settles down, either for the medics who leave or for the NHS that is kicking them out.

    Hi Potentilla. Good to see you here. You are right about the lack of experience, and I’ll add that point in later today. I too know doctors who are uncomfortable about their lack of ward-time.

    Thanks for reading, both of you. And thanks for posting. I assume you’ve signed the petition asking the government to put control of medical training back in the hands of the Royal Colleges? http://petitions.pm.gov.uk/medicaltraining/

    It’s only going up by about 500 a day, and that worries me.


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  19. Like many replying, I’m a Junior Doc too. Excellent explanation! Potentilla is absolutely spot-on too!

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  21. Potentilla is good peeps, Graham. Thanks for reading and thanks for commenting. Likewise, Sol, thanks for the link. The more we can spread the word from the patients’ eye view the better. In the long-run the docs will be all right (or that’s my mantra at the moment). In the long-run it’s the NHS and therefor us that will suffer.


  22. Excellent piece and website, however
    ” For those who were not selected by the MTAS process two weeks ago, their chance to continue as specialists has gone for good. They are explicitly prevented from applying again.”

    Is not strictly true, there is a second round later in the year and there will be slots opening up due to natural fall-out in the coming years. Whilst I don’t think this is enough if you are to get the non-medical community on your side you have to be absolutely correct about the facts you present.

  23. Ye-es. The problem with putting forward simple explanations of anything this complex is that once one starts caveating things, it gets – well – complex. I do take your point though.

    The Round 1 / Round 2 situation is slippery at the moment and appears to differ from deanery to deanery. Some are comfortable with the robustness of the system because they have used it before and will be filling from Round 1 whenever possible. Others are not comfortable and are only appointing from a percentage of their Round 1 interviewees, on the basis that there may be some golden lads and lasses badly served by MTAS in Round 2.

    “The slots opening up due to natural fallout” strikes me as a fob-off and is most certainly a case of the government wanting it both ways. There may well be suitable candidates washing around the system for a couple of years locumming or taking trust grade jobs, but that will soon cease to be the case, and then we’ll have holes in the service. Again.

    I will change the wording though, because it is a little bit too absolutist as it stands.

    Thanks for your comments Louise.


  24. I agree the whole thing is complex, what happens if a doc from Round 1 misses out on one of his choices because the deanery decide to wait until the second round and then the deanery realise the doc from the first round was their best fit! Too late for the first doc. (This is not to say the second round docs are second-rate just as a best-fit point of view).

    I think what gets my goat most of all is non-medics saying well we all have to compete for jobs why shouldn’t the doctors – if non-medics knew the real situation they would realise that this isn’t comparable to any non-medic job situation and your website is a great place for them to come and see that.

    I was under the impression that another reason for implementing this rigid career path was that before MMC newly qualified doctors could graduate and then spend some years taking jobs (which they had to apply and be accepted to of course!) and getting experience in different specialities before they decided what they wanted to specialise in, the gov’t saw this as wasteful time (and not what in fact it was – the bulk of the NHS workforce) and now give doctors just 2 years (F1 and F2, which involves I think 6 rotations) before forcing them to decide on a speciality.

  25. Louise, the internet ate my updates. I’ll try to get some time to make changes based on the comments I’ve already recieved from you and others later today.


  26. MTAS new system has made it difficult to get information.

  27. Has it? I’ve lost direct touch with it, and there is a lot more information about MMC and MTAS out there than there was when I wrote this.

    Thanks for reading and commenting .


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