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College Responses to Professor John Tooke

20 November 2007

Dear Sir John,

Re: Royal College of Surgeons of England response to interim findings and recommendations of the Independent Inquiry into MMC led by Professor John Tooke

The Royal College of Surgeons of England welcomes your excellent analysis of the problems that have occurred recently with regard to the development and implementation of MMC and MTAS and the wide ranging set of recommendations and potential solutions you have put forward.

Your interim report reflects the views of a large and wide ranging group of stakeholders, including a large number of young doctors in training for whom MMC and MTAS has been a hugely stressful and unhappy time. We have, through your endeavours, the opportunity to put in place the right structure and support for teaching and training the next generation of doctors in order to maintain and promote the highest standards of care for our patients.

Our response does not seek to address all aspects of your interim report, just those recommendations we see as key to future success, in the order in which you have presented them.

We recognise and support your view that removing the link between FY1 and FY2, and the reinstatement of the link between medical schools and FY1, will be to the benefit of U.K. graduates, guaranteeing them access to an FY1 placement. We agree that the principles enshrined in the Foundation Programme at FY2 should not be lost but should be encapsulated within broad-based core training curricula as you have recommended.

We welcome the opportunity to collaborate with colleagues across the medical profession to build cross-specialty core programmes which offer our young doctors a greater exposure to medical and surgical specialties, supporting informed career choices and providing  opportunities to learn from other allied specialties, prior to selection into a surgical specialty. We recognise the need for broad-based training as an original aim of MMC, responding to issues identified in Unfinished Business  and we welcome your support for going back to these basic principles.

We recognise that the introduction of a period of core training may be perceived as a return to basic specialist training particularly in highly competitive specialties such as surgery. We believe however that the introduction of a time-capped period of three years and properly managed core programmes supported by curricula that promote excellence and support flexibility will provide structure for this period of training. This provides a career pathway for our young doctors to move from broad-based core training into a specialty in a realistic time period and in a planned and structured way, through competitive selection using College-approved examinations and assessments.

An explicit statement is required that research in core training should provide exposure to research methodology and statistical analysis and should not be seen as a hurdle into specialist training. Substantial periods in research potentially leading to higher degrees should take place during higher specialty training. Opportunities for trainees to access Academic Clinical Fellowships during specialty training should be provided.

We believe that the role of the regulator is key to the future success of this process and that where it sits and what it does needs further careful consideration. We support your view that merger of PMETB within the GMC is appropriate, we would suggest that this takes place alongside a fundamental review of the role of the regulator in relation to other bodies involved in training our young doctors.

We support all endeavours to de-stigmatise trust grade posts, however there is anxiety about the impact on consultants’ capacity to train to an approved curriculum if trust posts have access to training as suggested.

Lastly, we note the recommendation that post-CCT doctors should spend a period in specialty posts from which they would seek access to consultant posts and recognise that there is a degree of inevitability about this. We believe that the time has come to reaffirm the commitment made in the NHS plan 2000 to provide a consultant-delivered service. We will develop a strategy for career progression during consultant practice which recognises the need to provide mentorship for newly appointed consultants. 

Our SAS Committee supports the creation of the new “Specialist” grade and views it as a major step towards official recognition of SAS doctors’ ability to practice surgery at the highest level.

The views of our Women in Surgery (WinS) Committee are attached.

In conclusion, we commend your efforts and look forward to receiving your final report, which we hope will remain largely unchanged.

Bernard Ribeiro, President

Women in Surgery (WinS) response to interim findings and recommendations of the Independent Inquiry into MMC led by Professor John Tooke

Women in Surgery, a subcommittee at the Royal College of Surgeons of England, welcome your detailed report regarding the development and implementation of MMC and MTAS. We support the broad intentions of the report and agree with the recommendations made, which are detailed, thorough and appropriate. We would, however, add the following points pertinent to women in the profession.

  1. The formation of additional FTSTA posts should be resisted. Such posts lack career prospects and provide those who fill them with no real hope of career progression. Traditionally, it has been women who have filled these roles.
  2. The proportion of women medical graduates should be considered. 60% of current medical school graduates are women and, since 1997, the annual number of women graduates has more than doubled. These women are likely to require time off from training and flexible training options to ensure they can pursue their personal and family goals, as well as their professional aspirations. If we fail to provide good training trajectories for these women, their talents will be lost.
  3. Less than full time training must be considered. Despite a commitment throughout the report to flexibility there is insufficient consideration given to less than full time or flexible training. The “Gold Guide” to postgraduate specialty training outlines the need to provide flexible training options but this need should be explicitly mentioned in all reports on selection.  The need for less than full time training is greater than that for flexible working as the Consultant contract allows negotiation of work patterns. Furthermore, a long-term job has less travelling time, and closer support networks than a series of training posts.  Ideally flexible training should be mainstream.
  4. Problems of geography must be addressed.
    1. The report comments that some Units of Application (UoAs) are too large; the size of these should be reduced. Any doctors with childcare commitments will not be able to travel easily to placements scattered across very large UoAs.
    2. One advantage of MTAS was the need to specify only 4 UoAs.  As national selection has now been removed, jobs will go to those trainees willing to travel around the country for interviews, rather than to the best candidates.
    3. Where training capacity allows, the option of inter-deanery transfers should be made available to ensure that the talents of those whose personal circumstances require re-location are not lost.
  5. The amount of time allowed out from training should be increased. The report comments that the trainee should “be allowed to interrupt their training for up to one year” (P99, recommendation 39). This should be qualified to provide opportunities for thoseparenting one or more children to extend this period.
  6. The recommendation that post-CCT doctors spend some time in specialty posts prior to consultancy should be carefully considered. Although this is intended as a step to consultancy care must to be taken to avoid these posts becoming a block to career progression. If the historical precedents of non-consultant posts are followed, these posts could become filled with women who are then unable to progress to consultant positions.
    We recognise that currently there are hundreds of excellent doctors who have committed to a career in their chosen specialty.  These people should be given the chance train and most of this cohort would prefer to have good quality training and then compete for Consultant posts.  However, after this bulge of senior trainees has passed, we should work towards matching training numbers much more closely with eventual Consultant and GP principal posts.
  7. Uncoupling ST2 and ST3 will encourage more competitive entry by encouraging all excellent candidates to compete for positions. It will further allow a fairer system by providing an entry point for those excellent candidates who have followed a non-regular career path (including career breaks, maternity leave, refugee doctors etc). Additionally, this will provide a point at which “average” candidates can be replaced with those who are “excellent”; this would not be possible with true run-through training from ST1 onwards.
  8. The report is right to highlight the possibility that the academic route will reduce options. The option for entry to academic medicine later in a trainee’s career should be left open.
  9. In conclusion, we commend your efforts and look forward to receiving your final report, which we hope will remain largely unchanged.

Yours sincerely

Helen Fernandes,

Chair, Women in Surgery