BMA response to the Independent Inquiry into Modernising Medical Careers –‘Aspiring
The British Medical Association is an independent trade union and voluntary professional
association which represents doctors from all branches of medicine all over the UK. It has a total
membership of over 139,000.
The BMA welcomes this independent and professionally-led inquiry into Modernising Medical
Careers, and the opportunity to comment on the interim report before its final publication later
in the year. The BMA views the recommendations contained in the report as an important
package that the profession can discuss and carry forward.
In order to respond to this report, the BMA has sought the opinion of all its internal
representative committees, a survey of members and an open conference for the profession ,
at which Professor Sir John Tooke presented his recommendations. In addition, the opinion of
delegates at a conference for clinical academic trainees3 was canvassed on how the
recommendations in ‘Aspiring to Excellence’ would affect academic medicine.
Some errata have arisen within the extensive report, detailed within Appendix 1; we hope this
will assist any future discussions.
• The BMA has been dismayed that the original principles cited in Unfinished Business
were discarded during the implementation of the new training system and concurs that
any future changes to the structure in postgraduate medical education should be
aligned with agreed policy objectives and guiding principles. It is agreed that there
should be an ‘aspiration to excellence’.
• The BMA agrees that the role of the doctor needs to be defined by the profession,
supports continuing debate and looks to facilitate further discussion within the
profession on this subject.
• The importance of UK-wide policy on medical education and training structures is
acknowledged and it is agreed that all four Departments of Health in the UK and the
four Chief Medical Officers must be involved in any moves to change medical career
structures. Appendix 2 contains a supplementary response from BMA Scotland which
covers areas where Scotland already has some solutions in place or where there will
have to be separate consideration due to different circumstances in Scotland.
• There is an urgent need for a coherent and accurate model of medical workforce supply
and clearly the way forward to produce such a model needs to be debated. It is
essential that the BMA is involved in the process of developing the content of higher
speciality training and workforce planning – in addition to input from the Colleges,
employers and medical workforce advisory machinery. The changing demographics of
BMA survey of members’ views: Tooke Inquiry - ‘aspiring to excellence’ an independent inquiry into
Modernising Medical Careers – 31 October 2007 -
Your training: the way ahead, 1 November 2007
Clinical academic training: the progress so far, 17 November 2007
the medical workforce and the demand for part-time and flexible training must also be
• The BMA acknowledges and supports the desire for a united professional voice and via
its participation in several cross-professional meetings and committees seeks to
harmonise professional messages to the government. Moreover, the BMA is very willing
to provide such leadership but does not feel that a single body – either an existing one
or a new one created for such a purpose – would fulfil all the desired objectives.
Instead, we suggest that it may be appropriate to establish ‘time-limited Boards’ for
specific issues as they arise, as have been implemented in 2007 e.g. MMC Programme
Board. The BMA will look to provide a conduit for all members of the profession to
voice their opinions, possibly through a joint forum.
• The BMA supports, in principle, the concept of streamlining regulation, such that the
PMETB is assimilated in a regulatory structure within the GMC. However, this
recommendation is only supported on the basis that the current financial arrangements
for the individual process should be improved and that the newly amalgamated body
has appropriate professional representation.
• The BMA believes that the Foundation Programme gives junior doctors a core, generic
two-year training programme on which they can build their specialist training. This will
improve the quality of the medical workforce as it will enable better understanding of
different fields of medicine as well as giving the doctors of the future a more complete
set of all round medical skills. The Foundation Programme also offers early exposure to
academic medicine, which is a vital to promoting academic careers. However, there are
issues with this format of training which require further assessment and discussion, such
as the value of four month placements and the provision of teaching. We would hope
the concept of the F2 year will be developed, and retained with ongoing improvement,
rather than be completely lost due to issues with its implementation. Therefore the BMA
disagrees with recommendation 33, which seeks to abolish F2, under the proviso that
there is a continuation of the assessment of the F2 year in particular.
• The BMA has always supported the concept of broad-based training and therefore
supports the notion of a three year core training programme followed by higher
specialty training. However, this should not result in enforced open competition in order
to move from Core to Higher training. There must also be multiple recruitment rounds
for Core and Higher specialist training throughout the year. We also agree that further
work on transferable competencies is essential.
• The BMA supports the recommendation that the length of training in general practice
should be extended to five years.
• The BMA supports early exposure to the potentials of a career in research/education. A
tailored menu of entry points for Academic Clinical Fellowship posts at ST1 and higher
should be offered to maximise opportunities for entry into pre-doctoral training posts,
both to recognise that interest in an academic career can develop over time and that
research in some specialties benefits from greater clinical experience.
• The BMA strongly opposes any proposed introduction of a post-CCT pre-consultant
specialist grade and believes that a new grade is not necessary. It acknowledges that
there are a number of factors which have resulted in the proposal for a new ‘specialist’
grade, but believes that these can be addressed by using the current structure within
the NHS and through optimal utilisation of the 2003 consultant contract
• The BMA is adamant that the key to de-stigmatising the staff and associate specialist
(SAS) role is through provision of Continuing Professional Development and the urgent
finalisation of the much-delayed SAS contract – the importance of recognising and
rewarding doctors in this grade cannot be emphasised enough.
5.1 Clarification of policy objectives
The BMA wholeheartedly agrees with the recommendations in this section. It has been
dismayed that the original principles cited in Unfinished Business were discarded during the
implementation of the new training system and concurs that any future changes to the
structure in postgraduate medical education should be aligned with policy objectives and
guiding principles. It is agreed that there should be an ‘aspiration to excellence’.
The BMA wishes to highlight recommendation 3; the government should not only consult, but
involve the profession in any policy development, particularly any policy changes that affect
postgraduate medical education and research.
5.2 The role of the doctor
The BMA and conference attendees agree that recommendation 5 is paramount if a successful
balance between service and training is to be achieved. It is acknowledged that while doctors
are diagnosticians, trainers, trainees, service providers, advocates for patients, recruiters and
those with the ultimate responsibility for patient care, it is difficult to encapsulate the role in
few words or gain a full consensus on a definition. The BMA supports continuing debate and
looks to lead and facilitate further discussion within the profession on this subject.
5.3 Policy development and government
The BMA noted in its evidence to this Inquiry that the lack of accountability within the
Department of Health led to its ‘Case for delay’ being ignored by the government. There were
also specific concerns relating to the disjointed implementation and decision making which in
turn affect the devolved nations and their recruitment and training plans.
The BMA welcomes the recommendations in this section and wishes to emphasise the
importance of the following statement in recommendation 10 –
‘All four Departments of Health in the UK and the four Chief Medical Officers must be involved
in any moves to change medical career structures.’
This was supported by 84% of respondents to the BMA survey, and must be adhered to if
cross-border flexibility and equality in training is to be preserved.
We agree that the active promotion of medical education in the NHS may be necessary and
support recommendation 9 which suggests that the creation of collaborative links between
local health and education providers should be a key appraisal target for Chief Executives of
Strategic Health Authorities (SHAs).
5.4 Workforce planning
The BMA endorses the recommendations on workforce planning. The profession recognises
that more accurate data is required and that published competition ratios for training posts are
vital for applicants to make informed decisions. It also agrees that government intentions should
be transparent and believes that there must be much more emphasis on and consideration for,
flexible and part-time working and training, in particular, the steady increase in the number of
women medical graduates needs to be acknowledged. The demand for flexibility and part time
working may also affect the total number of whole-time equivalents at the Consultant and GP
The wider political context, demographic changes in both the workforce and the patient
population and technological advances should also be assessed. There also needs to be a
greater emphasis on the management of expectations of trainees in the light of this
There is an urgent need for a coherent model of medical workforce supply and clearly the way
forward to produce such a model needs to be debated. It is essential that the BMA is involved
in the process of developing the content of higher speciality training and workforce planning –
in addition to input from the Colleges, employers and medical workforce advisory machinery.
The BMA stated in its response to the Department of Health’s consultation, Recruitment to
Foundation and Specialty Training - Proposals for managing applications from medical
graduates from outside the EEA4, that doctors subject to the immigration rules currently in the
UK should be able to compete for training places on equal merit, and believes that these
doctors should also be accounted for. We note the recent Appeal Court judgement on this
matter, and hope that the Department of Health will not appeal it further. We do agree,
however, that future applicants from outside the EEA must be advised that there is no
guarantee of training in the UK; this advice does not apply to refugee doctors who should be
considered alongside UK applicants.
Future migration from the EEA must also feature in workforce projections.
The BMA agrees that explicit policies need to be urgently developed to manage the transitional
‘bulge’ and the increased supply of medical graduates; including consideration of the numbers
and composition of UK medical school places and the likely need for a reduction should current
employment trends continue. Clear policies are required on the number of doctors needed in
There also remains an obvious need for careers advice for trainees and this must be based on
reliable data and workforce planning. Agreement is needed on the number of doctors required
The creation of a National Institute for Health Education, along the lines of the National Institute
for Health Research where funding for health research is earmarked and ring fenced, should be
supported. For too long medical education budgets have been raided for other uses; the
establishment of an Institute for Health Education to commission higher specialist training in
some subspecialties could be a first step toward safeguarding the funds for medical education
and driving up standards.
The BMA acknowledges the need for a united professional voice and via its participation in
several cross-professional meetings and committees seeks to harmonise professional messages
to the government. However, it is aware that there will, at times, be differences of opinion due
to the conflicting aims of stakeholders.
Recruitment to Foundation and Specialty Training - Proposals for managing applications from medical
graduates from outside the EEA, BMA response -
The BMA would like to highlight the success of the profession in working together in times of
crisis; this has been evident in the work of the MMC Programme Board, where all stakeholders
have come together with the intention of improving the situation for trainees. Therefore it may
be appropriate to establish such ‘time-limited Boards’ for specific issues as they arise.
It should also be noted that professional bodies, working together under the leadership of the
BMA, is not unprecedented. In 2004 the BMA held a summit for junior doctors at which all the
royal college trainee committees were represented, the outcome of which was a consensus
statement, which is appended to this document5. The Joint Medical Consultative Committee
(JMCC) is another example: this brings together the organisations that represent the medical
profession in the UK and provides another forum for members to debate and unite on issues
affecting the profession as well as taking these issues forward with the CMO and Department
The BMA will seek to replicate this work in future, on a wider scale, in an attempt to provide a
conduit for all members of the profession to voice their opinions.
We welcome the call for an increase in clinically qualified managers and an enhanced
awareness of the interdependency of clinicians and managers in the pursuit of optimal
healthcare. We, therefore, support the proposal for enhanced opportunities for training in
medical management during postgraduate training years and note that this is also something
the NHS Institute and BAMM are signed up to and are working on already. To be effective this
will need to be properly funded. We would also suggest that it should be focussed on (though
not exclusively available to) those interested.
5.6 Commissioning and management
In 1995/6 the BMA, led by the JDC, produced work for the Calman reform programme stating
that there should be a review of the Medical Postgraduate Deanery function in England. The
BMA therefore welcomes this recommendation and believes that the review is long overdue.
Graduate schools are already in existence in some locations and can offer improvements in the
delivery of postgraduate medical education where there is support for their establishment by
the relevant stakeholders. It is important that the BMA is represented in any proposals to
develop Graduate Schools more widely.
The BMA agrees that the responsibility for the local delivery of postgraduate medical education
and training should be part of the explicit remit of the Medical Director of Trusts or a specified
Director of Medical Education. However it believes that the link between the clinical tutor and
medical director must be maintained. The delivery of postgraduate medical education and
training needs to be fully resourced and supported by adequate time in consultants’ job plans,
via supporting professional activities (SPAs). Similarly, sufficient SPA time is needed for training
and staff development purposes. There is currently a widespread attack on the number of SPAs
consultants are able to have, due to the short sighted focus on pure service delivery. If post-
graduate medical training is to return to its previous status, the robust assessment and
teaching/training time required will need preservation and expansion of SPA time for many.
In evidence to the Commons Health Select Committee into NHS deficits, the BMA expressed
concern that NHS deficits were adversely affecting the delivery of medical education and
training in the 2006-07 financial year as SHAs made cuts to MPET budgets to create a
contingency fund for the NHS. The BMA also made representations to the Department of
APPENDIX 3 - Consensus statement reached at the Modernising Medical Careers Trainees’ Forum
Health expressing concern that Service Level Agreements between the Department of Health
and Strategic Health Authorities were insufficiently robust to safeguard the delivery of medical
education and training and called for the reinstatement of University representation on SHA
Boards. We agree that postgraduate medical deans should have improved accountability links to
medical schools and SHAs.
5.7 Streamlining regulation
The BMA supports, in principle, the concept of streamlining regulation, such that PMETB is
assimilated in a regulatory structure within the GMC (this was also supported by 61% of survey
respondents). Potential benefits include 1) removal of duplication of audit, governance, board
structures (with consequent cost saving), 2) spread of the cost of PG certification to all doctors,
thus not over-penalizing trainees, 3) greater consistency of approach and a joined up
educational strategy across undergraduate, postgraduate and CME/CPD education, 4)
accountability to parliament, and not government,
In addition to concern regarding the potential for the merged bodies to result in altered fee
levels, there is concern regarding the make-up of the overseeing Council and how it would be
elected. Clearly more details on the proposals are needed.
The BMA would also like clarification of how this recommendation will fit with the
recommendation in the recently published White Paper ‘Trust, Assurance and Safety’ , which
states the contrary view that:
‘The Government agrees with the proposal, set out in the GMC's response to consultation, for a
three-board model covering undergraduate education, postgraduate education and continuing
professional development. The Department of Health will work with the GMC to establish an
undergraduate board and a continuing professional development board in the GMC. The
PMETB will continue as a separate legal entity, fulfilling the role of the postgraduate board
within this three-board approach. Both organisations will continue to have a duty of co-
operation….The Government will review the effectiveness of these new arrangements in 2011
to establish whether any further integration of postgraduate medical education would be
5.8 Structure of post graduate medical education
The BMA welcomes reassessment of the training and SAS grades, but remains unconvinced that
changes to the name of any grade will help to de-stigmatise or reaffirm their place within the
structure. Many grades have recently undergone renaming processes and it would be unwise to
alter any title without thorough consultation with the grade itself, and only if accompanied by
real and visible changes that improve the status of that grade.
Piloting and trialling will be vital to the profession accepting any significant changes so soon
after the failure of MTAS. As the report states, all new policies and suggestions should be
evidence based and agreed by the profession before implementation.
In addition, regular assessment of progress and competency, which is measured against
effective and applicable criteria, should be a central component of all training programmes. This
should be coupled with agreed mechanisms for support and redress where there is under-
Trust, assurance and safety: the regulation of health professionals (Executive Summary, paragraph 23) -
performance. Such issues should not be dealt with at the next stage of recruitment/competition,
but during the training itself.
5.8.1 Foundation programme
Throughout the report there are references to broad-based education and the necessity for the
doctors of the future to be adaptable. The BMA agrees with these statements and believes that
the Foundation Programme gives junior doctors a core, generic, two-year training programme
on which they can build their specialist training. This will improve the quality of the medical
workforce as it will enable better understanding of different fields of medicine as well as giving
the doctors of the future a more complete set of all-round medical skills. In addition, the
Foundation Programme was first piloted in 2003 and has a curriculum and assessment process
in place that is tried and tested.
The report also acknowledges that FY2 is currently too early to determine which specialty a
trainee wishes to pursue, but then goes on to suggest that a trainee should apply for core
specialist training, after six months post-graduation. Many trainees do not know which specialty
would suit them best at this point. Many in the cohort will not have worked in a specialty to
which they wish to apply. There is evidence trainees alter their specialty choice as a result of
experience, therefore an extra year of training is preferable prior to deciding to which core
specialty training route to apply.
Another consideration when discussing the future of the Foundation Programme is that it has
been implemented throughout the UK, and altering this process would be likely to lose this
uniform state. If one of the four countries did not go along with the recommendation and
remained with a two-year programme we would have a situation whereby postgraduate
training would not coincide across the UK, thereby reducing the portable aspect of training
within the UK.
However, the BMA is concerned about the evidence that some junior doctors have not
benefited from their Foundation Year 2 placements. There are issues with this format of training
which require further assessment and discussion, such as the value of four month placements
and the provision of teaching, however we would hope the concept of the F2 year would be
developed, and retained with ongoing improvement, rather than be completely lost due to
issues with its implementation. Therefore the BMA disagrees with recommendation 33, which
seeks to abolish F2, under the proviso that there is a continuation of the assessment of the F2
year in particular.
Computer adaptive tests
The BMA requests further detailed information on the idea of computer adaptive tests.
Specifically the purpose of the tests needs to be clarified, whether they would be used:
• as a ranking exercise
• to help junior doctors make career decisions
• as assessments where results are passed to future employers.
Any test that is used must be backed by good experimental evidence showing that it works. The
tests would have the effect of changing all the curricula in the UK, and students would
therefore start learning in a way that is appropriate for the tests, which may not necessarily
make them better doctors.
5.8.2, 3 & 8 Specialty training
The BMA has always supported the concept of broad based Core Medical Training, as cited in
its discussion document ‘An integrated training system’ , and therefore supports the notion of a
three year core training programme followed by higher specialty training. However, this should
not mean enforced open competition between the sections. Some specialties are suited to run-
through training and should not be forced to ‘decouple’ without valid reasoning, while some
are more suited to a defined split in the curriculum. Thus a mixed economy is essential. The
BMA believes this is a decision for the MMC Programme Board.
The BMA is pleased that the report recommends that doctors who are unsure during the early
part of their training as to which core specialty they wish to pursue are able to take some time
out in hybrid rotations. However, these hybrid rotations should be training posts and ideally all
posts which are relevant to the final choice speciality should count toward the completion of
their core specialty training.
As highlighted in the BMA evidence to this inquiry,8 and by attendees at the BMA conference
on the recommendations, there must be multiple recruitment rounds for Core and Higher
specialist training throughout the year (e.g. two recruitment (or more) rounds per year).
The BMA has also been consistent in its calls to the Royal Colleges to work on transferable
competencies, hence the BMA’s unequivocal support for Recommendation 36. Within training
there must be robust and tested transferability of competencies to allow the aspirations of a
broader curriculum under core training, and to allow flexibility for movement between
specialties as required for workforce planning and for career development and choice. There is
an urgent need for the Royal Colleges to produce clear proposals on how this will be done.
The BMA is pleased to see renewed emphasis placed on out-of-programme experience and
welcomes Recommendation 39. In these instances, however, there also needs to be a
guarantee that junior doctors can retain their training number and enter back into training. In
addition, a limited number of training posts should be made available, within a reasonable time
frame, appropriate for individuals who develop an illness or medical condition that precludes
them completing a specialty training scheme and affords them the opportunity of retraining in a
different specialty, usually within the same deanery or SHA.
Unfortunately the same emphasis is not placed on flexible or part-time training and the BMA
urges more work in this area to ensure it is accessible to those who seek it.
The BMA believes that the introduction of any specialty assessments and selection centres needs
to be supported by robust methodology and evidence of their validity as a selection tool.
Selection tools that score candidates, rather than a single test, would be preferable and must be
able to distinguish between candidates of varying abilities. Further clarity is needed on the
mechanisms envisaged, how they will be tested and resourced, together with a detailed analysis
of mechanisms, such as RITAs, which are currently in place. This must also include increasing
the robustness of assessment to ensure that those who progress are truly up to the required
standard. In addition, appropriate resources (e.g. consultant SPA time) are needed to allow this
to be delivered.
An integrated training system, JDC 2001 - http://www.bma.org.uk/ap.nsf/Content/integratedtraining
BMA evidence to the Tooke Inquiry - http://www.bma.org.uk/ap.nsf/Content/Tookereview
The BMA supports the recommendation that the length of training in general practice should
be extended to five years; 70% of survey respondents agreed. However, our agreement comes
with the proviso that the extension to training must focus on the GP curriculum throughout and
must be relevant to their future GP career. Training to be a GP must be the primary focus. We
would be concerned if GP training were to encompass three years in hospital with a service
In order for this recommendation to be successful it is essential that GP trainers are adequately
supported and remunerated. The retention of GP trainers is of great importance when
considering GP training for the future.
Academic placements during the Foundation Progamme are an important opportunity for
trainees to gain exposure to academia before making a decision about which career to pursue.
They are not a prerequisite for entry to an Academic Clinical Fellowship (ACF) posts, but can
assist an application and allow a trainee explore early potential interest in an academic career.
Delegates at the BMA academic training conference agree that these placements, or
alternatives to them, are especially important for academic medicine following the significant
decline in the academic workforce since the year 2000. Such opportunities must be retained
and made available to trainees either during foundation training or any future equivalent.
ACF posts are currently offered at a number of entry points because interest in an academic
career can emerge at different stages of postgraduate training. Further, some specialties require
that a higher level of clinical experience be obtained before research can be usefully undertaken
and set entry to ACF posts at ST2 or ST3 accordingly. Differential ACF entry points acknowledge
that it is important to tailor posts to the trainee and to the clinical and academic opportunities
available locally. The BMA and delegates that attended the academic training conference
disagrees with the suggestion that entry to all ACF posts should migrate to ST1. A mixed
economy of numerous entry points to pre-doctoral academic training that is appropriate to the
specialty, and the local clinical and academic circumstances should continue. Maintaining this
flexibility is vital to maximising opportunities to enter academic training during Core Medical
Most Walport Clinical Lecturer posts are currently offered at the equivalent of ST3 and beyond,
which is appropriate. We therefore support recommendation 42.
The ability to undertake out of programme experience (OOPE) is extremely valuable and should
be maintained and increased. Formal academic training through ACF and CL posts were never
intended to be the sole way of developing and maintaining the academic workforce and
continued opportunities to interrupt training to seek alternative experience is essential. The
BMA sees no reason increase the hurdles to undertake OOPE by limiting the period of
alternative experience to one year as suggested in recommendation 39, especially when higher
degrees take three years to complete.
Recommendation 44 suggests that Senior Lecturer appointment should be conditional on
possession of a CCT. Limiting appointment to Senior Lecturer posts to those in only possession
of a CCT would reduce access into senior academic posts at a time when efforts should be
made to improve entry into academia. Given that there are, and will continue to be, diverse
academic training paths and entry to the specialist register can be made via Article 14
applications to PMTETB, the BMA considers that entry to the specialist register should be the
defining characteristic of a senior lecturer appointment.
5.8.6 Post CCT careers
The BMA strongly opposes any proposed introduction of any post-CCT, pre-consultant specialist
grade and believes that a new grade is not necessary, nor advantageous in terms of quality of
care or finance. It acknowledges that there are a number of factors which have resulted in the
proposal for a new ‘specialist’ grade, but believes that these can be addressed by using the
current structure within the NHS and through optimal utilisation of the 2003 consultant
contract. In particular, the appropriate use of job planning, objectives and supporting resources
provides the framework for dialogue between consultants and their managers to match
consultant workload and skills to patient needs.
It has been argued that the reform of postgraduate education and training, and the earlier
award of the CCT, may produce CCT holders with inadequate experience to immediately take
up a consultant appointment. The end-point of specialty training – the CCT - must be fully
trained consultants and general practitioners; anything less than this would be an unacceptable
outcome of a modernised training system. The standard of a CCT must equal that of a CCST. If
there is concern that this is not possible within a given system then the system itself, or the
length of training within that system, should be revised. A key element to this will be rigorous
assessment (and appropriate training and (time) resources to do this) by consultants. It is
essential that progression through training truly reflects increasing acquisition of knowledge
skills and appropriate attitude rather than just time served. In conjunction with this there needs
to be careful careers guidance and management of aspirations to ensure that the value of the
CCT is not reduced and all those achieving this standard are suitable for taking up independent
consultant practice. This should not detract from increasing the recognition and reward of
alternative career roles for those not wishing, or able to progress, at that time, to consultant or
The expansion in medical school numbers and specialty training posts means that there will
inevitably be a large increase in the number of doctors holding a CCT if current progress
through training continues. Robust data is needed as a matter of urgency to determine the
demand for consultants (within each speciality) and therefore the optimum level of consultant
expansion needed within the service. If the potential supply of CCT holders is significantly
greater than the demand for consultants, then there needs to be earlier acknowledgment that
other career paths may need to be considered by those in training.
Hospital consultants are highly-specialised doctors dealing with a complex and demanding
workload, and lead multidisciplinary teams to deliver high quality patient care. They are also
best able to cover the generality of secondary care to the highest quality patients deserve. They,
along with their GP colleagues, are key to the success of the NHS and are central to service
innovation and development, including clinical research, which ensures that the most effective
care pathways and treatments are available to patients. Patients deserve the best possible
standard of care, with complex care being delivered by consultants. The BMA believes that
patients will be best served by a consultant based service rather than a purely consultant
delivered or limited consultant led service. There is neither need nor place for a new specialist
hospital grade. In addition patients are increasingly demanding to see consultants, rather than
doctors of other grades, and patient choice will continue to increase this trend. Recognising the
benefits of a consultant-based service can deliver both these needs and demands.
There is still a significant need to increase the number of consultant posts to benefit the service,
enhance the quality of care and facilitate team working. The expansion of doctors in training
must therefore be accompanied by a controlled expansion in the number of consultant posts, so
that the long-term needs of the service, its likely development and the demands of education
are fully considered. The future hospital service should be a consultant- based service, where all
major decisions and much of the more specialist care of patients is delivered by consultants and
all care is led by consultants. However, not all care needs to be, or should be, delivered by
In the short term, a new specialist grade may be perceived by some to be a more affordable
option to controlled consultant expansion. However, there is a body of evidence that strongly
suggests that where patient care is delivered or led by fully-trained consultants the service is
more efficient. Lower patient admission rates, reduced length of stay, lower mortality rates and
fewer complications can benefit trust finances. Furthermore, when given the time and
resources, consultants are able to innovate and develop new care pathways and treatments that
benefit the service and patients. There is already considerable flexibility and adaptability within
the consultant contract that can and should be used in partnership between consultants and
their employers. In particular the use of SPA time and proper use of objectives and necessary
supporting resources can deliver the incentives and tools needed to promote the varied
“portfolio” type consultant career that removes the need for any new grade. In addition there is
the Clinical Excellence Awards scheme (and equivalents in Wales and Scotland) to encourage
excellence and enhance performance. This model would maintain the integrity of the consultant
grade and would meet the aspirations of doctors in training who wish to become consultants,
rather than specialists. Assurance is needed from the Health Departments that they continue to
envisage services being provided by consultants and that they will make the necessary
provisions to determine the optimum number of consultants within a consultant-based service
and develop the service accordingly. Patients deserve no less.
5.8.5 Trust registrars
When assessing the situation for Non Consultant Career Grade doctors, much greater
consideration of current trainees and SAS doctors is necessary. The BMA agrees that this role
should be de-stigmatised and made a more attractive career choice but envisages that this will
be achieved in three key ways.
First, through the provision of Continuing Professional Development and the urgent finalisation
of the SAS contract – the importance of which cannot be emphasised enough.
Second, there is a need to move to a situation where the distinction between training and non-
training posts is diminished as all posts should have an element of continuing education and
development which, in the case of Staff and Associate Specialists would help to ensure that the
opportunity, for those willing and able to make the progression to CCT-holder, was a realistic
one. Opportunities to apply for training posts must be made available at all levels of entry for
those who wish it along with support for those who wish to apply for specialist registration via
the article 14 route.
Third, consideration must be given to a means of providing an aspirational higher level for those
who have made the SAS grades a positive career choice.
On the whole, Professor Sir John Tooke and his team should be commended for their
independent inquiry, which is an excellent, wide-ranging, overview of the issues currently facing
postgraduate medical education. It makes valid assessments and recommendations which we as
a profession must, and will take forward. Where there is still contention and further discussion
is required, the BMA is ready and willing to provide a forum for this and lead progress. The
BMA remains determined to work with all other stakeholders to find resolutions to the essential
questions posed within the report.
• Page 31 - ‘Achieving a balance proposed a 2% pa increase in the number of
consultants…’ The document ‘Achieving a Balance-Plan for Action’, 1987, states on
page 42 that ‘A number of alternative projections were studied, but the one that
seemed best to exemplify the package of measures finally adopted was based on the
following assumptions: - Consultant expansion is boosted by an additional 50
posts a year for 10 years, that is to say about 2.8% pa.
• Page 61 – these figures were not shared with the BMA.
• Page 68 – ‘Further 95% of patient contacts in the NHS take place in Primary Care’. This
statistic is not fully relevant, as primary care consultations cannot be compared with
finished consultant episodes – by nature they are different and a finished consultant
episode can be extremely lengthy.
• Page 85 - The words “certificated specialist” should be deleted from recommendation 5
as there is no such grade in the NHS.
• Page 144 - An academic scoring system is reproduced. This is the 'emergency' scoring
template developed by BMA MASC, members of the 'Walport' committee and the
wider academic community mid-way through round 1 for the Review Body. It was used
for rescoring ACF applications (in England) in order to identify individuals who had not
been offered round 1 interviews. This led to quite a few candidates being offered
interviews and some posts.
As this template has had considerable input and wide consultation from the academic
community, the statement on p145 is therefore not correct: 'It is clear that...the
academic community was not involved in the allocation of scores for the academic
questions which are shown in the table opposite'.
It would of course be correct to say that academics had little or no input into the
‘original’ scoring system for round 1. But this scoring system cannot be reproduced
because it does not exist - this was part of the problem for which the academic
community developed the emergency scoring template described on p144.
ASPIRING TO EXCELLENCE: THE TOOKE INQUIRY INTO MODERNISING MEDICAL
Supplementary response from BMA Scotland
BMA Scotland is grateful for the opportunity to submit this response to the recommendations
of the Aspiring to Excellence interim report with particular reference to Scotland. This evidence
supplements that submitted by the BMA on a UK basis, which we support and endorse.
We have noted that the analysis of events in the report is heavily focussed on England and that
it was only able to take limited account of the different circumstances that exist in the devolved
nations. It should therefore be acknowledged that the wording of some of the
recommendations are not directly relevant to Scotland, or are phrased in such a way as to leave
doubt over whether they should also have applicability in Scotland.
BMA Scotland would like to raise some specific issues in relation to Scotland, as follows:
Clarification of policy objectives:
Recommendation 3: Healthcare is a devolved responsibility and there are significant
differences in policy, implementation, workforce considerations and service delivery in Scotland,
which have an impact on postgraduate medical education and training. There are two policy
imperatives to be considered – those of the Scottish Government and those of the Westminster
Government in relation to reserved matters.
Role of the doctor:
Recommendation 5: With reference to the need for a common shared understanding of the
roles of the doctor in the contemporary healthcare team, there needs to be recognition that this
understanding may, appropriately, differ in Scotland. For example, the CMO for Scotland has
repeatedly indicated that there is no appetite in Scotland for a ‘certificated specialist’ other than
in the consultant or GP principal role and BMA Scotland supports this view.
Policy development and governance:
Recommendation 7: It would be helpful if it was clear that all relevant stakeholders MUST
include those from the devolved nations.
Recommendation 9: The infrastructure which underpins the health/education sector
partnership in Scotland is very different from England and we would suggest that it is working
well. There is a Special Health Board, NHS Education for Scotland (NES), which has responsibility
“for supporting NHSScotland Boards and their staff to deliver patient care through targeted,
effective training and education”. As far as postgraduate medical education and training is
concerned, NES hosts the 4 Scottish Postgraduate Deaneries, and holds the funding for trainees’
salaries. This is very different to England where the SHA employs the Dean, and holds a budget
for both service and training.
Similarly, the (Scottish) Board for Academic Medicine, involving the Universities, the NHS
employers, NHS Education for Scotland, and the Scottish Government Health Directorates
(SGHD) is an example of how Scotland has sought to forge the functional links referred to in
this recommendation, although the Board lacks input from the broader profession.
Recommendation 10: Recognition of this issue, and the need to involve all four Departments
of Health and their senior officers, is crucial. We see no reason why DH (England) should
automatically have the lead role, indeed we could argue strongly against it, given that many of
the problems with MMC 2007 and MTAS stemmed fundamentally from DH(England) and
MMC(England) seeking to impose solutions on a UK wide basis that were particularly
inappropriate for a Scottish context. All the nations in the UK have an equal interest in
postgraduate medical education and training and policy decisions should not disadvantage any
Recommendation 11: There needs to be clarity on the Scottish dimension here also. It is
equally important for the Scottish Government to “have a coherent model of medical workforce
supply” but immigration policy will be determined at a UK level.
This recommendation should make clear that in determining such policy, “all four Departments
of Health in the UK and the four Chief Medical Officers must be involved” as set out in
Recommendation 12: Although workforce planning is probably better in Scotland, it is still
imperfect and most (although not all) of the bullet points would merit discussion specifically in a
Recommendation 13: We would point out that the GMC information may be limited: it may
know who is registered/certified, but has no data on whether or not these doctors are working,
nor for what they are training. In Scotland, we have better data on doctors in training, via NES.
Recommendation 16: The oversupply of medical graduates is a UK-wide issue and there will
have to be UK-wide solutions because of the UK-wide job market. In Scotland, the coming
problem is the retention of the ‘St Andrews 100’, for whom there is no commitment that we
are aware of to fund foundation posts, let alone run-through training.
Commissioning and management of postgraduate training:
Recommendation 21: We would suggest that Scotland already has a lead for medical
education through the Medical Director of NHS Education for Scotland, with policy
responsibility resting with the Education and Learning Unit of the SGHD. However there is
sometimes confused accountability between NES and the SGHD over policy.
Recommendation 22: There are separate and distinctly different arrangements operating
currently in Scotland, with NHS trainee workforce numbers being decided by the SGHD and
NHS trained workforce numbers being decided by NHS Boards as employers. However, as we
have said elsewhere, workforce planning in Scotland is imperfect and there is a dichotomy
between the future trained workforce numbers being projected by Boards and the output of
CCT holders from the training system.
Recommendation 23: We would suggest that in Scotland, the funding flows already reflect
training requirements and the contributions of service and academia. Funding for postgraduate
medical training is held by NES, as is funding for the additional costs of undergraduate
Recommendation 24: In Scotland, the postgraduate deaneries are accountable to NES and we
do not consider that a review is necessary here.
Recommendation 25: Accountability links between the Postgraduate Deans and medical
schools already exist in Scotland. All Deans have at least honorary university contracts and some
are university employees.
Recommendation 26: This recommendation for Graduate Schools sound a lot like the Scottish
Specialty Boards for Training (previously Transitional Boards), which “reflect the crucial interface
function played by the medical Postgraduate Deanery between the service, the profession,
academia and workforce planning/commissioning”. The service and workforce input into the
boards probably needs further work, but the basic structure is in place in Scotland.
Recommendation 27: We would point out that priority for education and training is already
integrated into GMC / PMETB standards, which NHS boards in Scotland are required to meet, as
part of the quality assurance arrangements.
Recommendation 28: PMETB Standards require that there is a nominated Board (in Scotland,
NHS Territorial Board) member with responsibility for education and training. The PMETB
standards have been drawn to the attention of all NHS Board Chairs / CEOs / Medical Directors
The structure of postgraduate medical training:
Recommendation 37: We do not have Trusts in Scotland and therefore the proposed title of
“Trust Registrar” is inappropriate in Scotland. “Registrar” is also a title associated with a junior
doctor training grade. We do not understand how this post would differ either from the
existing staff and associate specialist (SAS) grades in Scotland or the proposed grade resulting
from the negotiations on the new SAS contract.
Recommendation 38: We consider that Staff Grade postholders have generally experienced
less “stigmatisation” in Scotland. They are seen as valuable members of the team and staff
grade posts have been regarded as a positive career choice by many doctors. As has been seen
from this year’s StR recruitment process, they can also be a route back into training.
Recommendation 41: It should be noted that there is a separate programme in respect of
academic training in Scotland, the Scottish Clinical Research Excellence Development Scheme
(SCREDS). However, while England has now had several rounds of ACF posts being advertised,
Scotland has not achieved similar progress. There is little information in the public domain
about how this scheme will operate and we are unaware that any NES clinical lectureship posts
have yet been advertised. This may lead junior doctors interested in pursuing a medical
academic career in Scotland to look elsewhere for opportunities, which will be a significant loss
of potential academic talent. We are also concerned that with SCREDS posts being created
using “rebadged” SpR posts, we will see the same specialties (such as cardiology, renal
medicine and oncology) taking the lion's share of the SCREDS posts whilst comparatively
research-light specialties (such as emergency medicine, obstetrics and gynaecology and
psychiatry) will struggle to get anything.
We do not understand the comment about the “need to ensure that those entering an
academic training path in the devolved nations are not disadvantaged when moving between
research and clinical activities”. The same is surely true of the English system.
Recommendation 42: Scotland will need to consider whether to review SCREDS in the light of
any new training structure that might emerge from the report’s recommendations.
reached at the Modernising Medical Careers Trainees’ Forum, held on Thursday 4
March 2004 at the Kensington Close Hotel, Wrights Lane, London W8 5SP
• End point of medical training
• The foundation programme
• Specialty training programmes
• List of attendees at the forum
End point of medical training
1. We believe that doctors trained to be generalists within a given medical field may in fact
require more training than those trained for a narrow sub-specialty. The current proposals
risk undermining public confidence in the NHS, in a government drive to produce
‘consultants’ in name only for political expediency.
2. The end-point of training should be medical consultant or general practitioner, who:
- Is an independent medical practitioner
- Is ultimately responsible for the patient
- Has the ability to deal with the vast majority of clinical scenarios within his/her specialty
- Is able to recognise when to refer
- Has completed a recognised training scheme
- Must have achieved independently verified competencies
- Should be actively involved in ensuring professional integrity and lead in service -
- Is committed to continued professional development.
3. Consultants should continue to be of equal standing, with no stratification within the
consultant grade. Although we recognise that the roles played by consultants may differ
throughout their career, we cannot support the creation of a junior consultant grade, or
whatever it may be termed.
4. Time spent in training programmes may differ depending on the specialty and upon
individual rates of achieving competencies. Competency-based assessment should have a
positive effect as it will allow a fixed end-point within variable training times.
5. General practice training should have equal standing with training in other specialties.
6. A PMETB, independent of government, in conjunction with the medical royal colleges,
should determine end-points of training.
The foundation programme
7. National implementation of the foundation programme should be delayed until there is
clear development of a curriculum for the entire programme; until pilots are finished and
evaluated; and until PMETB has had time to consider training standards and quality
8. The foundation programme should be primarily focused on training junior doctors and not
about service provision. Foundation programmes should provide the opportunity to develop
training based on structured curricula with clear learning outcomes, rather than on service
9. There needs to be flexibility within the foundation programme to allow trainees to modify
the F2 year in light of the experience gained in F1.
10. Doctors entering either foundation programmes or traditional PRHO posts during piloting
and roll out of the programmes must not be disadvantaged in their career as a result. Pilot
posts must have prospective educational approval by the colleges or PMETB.
11. The introduction of generic foundation programmes is welcomed. These should contain
modules of competency to provide the basis on which to build future competence:
including assessment of patients (including critically ill patients), communication skills,
understanding and interpreting research evidence. They should allow exposure to the
specialties that may have been given less focus in medical school education.
12. We are pleased that full GMC registration will continue to be granted at the end of the first
year of training (PRHO/F1).
13. Career planning and mentoring is a continuous process that should begin at medical school,
and run throughout one’s career. Those providing career guidance must be fully trained and
resourced and there needs to be identifiable methods for people to access advice.
14. Good, realistic, career guidance and mentoring should be provided by properly trained
people removed from the appraisal/assessment process.
15. Due to the expansion of the workforce, new money must be available to accommodate
increased numbers of graduates. There should be enough flexibility to allow numbers to
vary year to year to reflect career needs of individual trainees.
Specialty training programmes
16. One model and length of run-through grade will not fit all specialties
17. There should be flexibility within programmes:
i to carry forward relevant competencies already attained in another specialty when
changing career path
ii for fully funded flexible and part-time training
iii to return from out-of programme training or research.
18. There must be flexibility in any training programme to both accommodate people whose
choice of final specialty is apparent, and those who have yet to decide their final specialty.
19. Sub-specialty training must occur within a training grade.
20. There should be an appropriate career path developed for those who wish to pursue a
career in academic medicine.
21. We welcome a review of the interface between basic and higher specialist training.
22. Staff and associate specialist doctors deserve appropriate recognition, career progression
and autonomy within defined boundaries.
23. There should be clearly defined entry criteria to the staff grade and associate specialist
24. Any doctor must meet the same criteria before being eligible for the award of a specific
CCT and appointment to a consultant post
25. We welcome the introduction of competency-based assessment and hope that this reform
will replace other less valid and unfit-for-purpose methods of evaluation.
26. Training should be the focus and priority of any training post.
27. All training posts should be properly structured with time set aside for protected
educational sessions and a named person taking responsibility for each trainee’s educational
28. All doctors should have a broad base of training, achieving competencies cultivated by
proper educational appraisal. There should be ongoing continuous assessment by trained
medical educators. Competencies and educational end-points should be clearly defined for
each stage of training.
29. Each training post should be trainee-centred. For instance, both a paediatrics trainee and a
GP trainee working within the same team should expect to receive training appropriate to
their own specialty.
30. Sufficient resources for both the trainer and the trainee must be provided. Time is
considered to be the most important resource.
31. Present study leave provision and regulations are not fit-for-purpose and will need to be
reviewed and reformed as part of the MMC process.
32. Teachers must be taught how to teach properly.
33. Teaching should be considered a valuable part of a person’s professional portfolio of skills
and should be rewarded appropriately.
List of attendees at the forum
In the chair:
Mr Simon Eccles Chairman, BMA Junior Doctors Committee (JDC)
Mr Roger Currie Chairman, Academy of Medical Royal Colleges Trainees Committee
Dr Simon Calvert Deputy Chairman (Education & Training), BMA JDC
Andrew Havers Clinical Lead, Modernising Medical Careers Programme, Department of Health
Ewen Sim Chairman, Communication Strategy, Postgraduate Medical Education & Training
David Tolley Consultant urologist
Jo Huang President of the Association of Surgeons in Training (ASIT)
Angus Robertson Honorary Secretary of the British Orthopaedics Trainees Association (BOTA)
Declan Chard Chairman, Royal College of Physicians of London Trainees Committee
Ben Carrick BMA Medical Students Committee
Simon Calvert Deputy Chairman (Education & Training), BMA JDC (SpR, A&E)
Ahmed Elsharkawy JDC Education & Training Team (SpR, gastroenterology)
Jo Hilborne Deputy Chairman (Terms & Conditions of Service & Negotiating), BMA JDC
Dave Macklin Deputy Chairman (Hours of Work & Medical Staffing), BMA JDC (SHO, A&E)
Raja Mukherjee JDC Education & Training Team (SpR, psychiatry)
Carolyn Atherley Royal College of Ophthalmologists
Masood Ahmed Junior Doctors Committee, BMA (SHO, psychiatry)
Steve Barden British Accident & Emergency Trainees Association
Jo Burgess Medical Students Committee, BMA
Ben Carrick Medical Students Committee, BMA
Sam Datta Junior Doctors Committee, BMA
James Down Group of Anaesthetists in Training
Adam Fraser Royal College of General Practitioners
Magnus Harrison Accident & emergency medicine
Jo Huang Association of Surgeons in Training
Khurshid Ghani Royal College of Surgeons of Edinburgh
Rajat Gupta Junior Doctors Committee, BMA (SpR, paediatric neurology)
Graham James Oral and maxillofacial surgery
Michael Irvine Junior Doctors Committee, BMA (SHO, medicine)
Steve Jones British Accident & Emergency Trainees Association
Stewart Lambie Royal College of Physicians of Edinburgh
Clive Lewis Royal College of Physicians of London
Geoffrey Lewis JDC Education & Training Team, BMA (consultant anaesthetist)
Rachel McMahon BMA Junior Doctors Committee (SHO, general practice trainee)
Geraldine Ng Royal College of Paediatrics and Child Health
Rao Nimmagadda Psychiatry
Ash Paul Faculty of Public Health Medicine
Angus Robertson British Orthopaedics Association
Francis Sansbury BMA Medical Students Committee
Bav Shergill British Association of Dermatologists
Kaji Srithiran BMA Junior Doctors Committee (SHO, cardiothoracic medicine)
Andrea Thirwall Otolaryngology
Melissa Whitten Royal College of Obstetrics & Gynaecology
David Wood Clinical pharmacology and therapeutics