Myths of MTAS and MMC

As we move ever closer to the start of August, there remains no sign that the MTAS (Medical Training Application Service) debacle will end. In the months since this sorry episode began, doctors have been united in a way never seen before,¹ and the common goals of those professionals who have invested so much of themselves in the NHS are becoming clearer: a fair, validated and transparent application process for all doctors; an expansion of training numbers combined with rational workforce planning; the preservation of those aspects of training which have made British medicine so respected; and, above all, the best possible care for the people who seek help from their doctor. Despite the apologies and the high-level resignations,^2-4 the government persists in its efforts to keep the sinking MTAS ship afloat. The Department of Health, its attention focused as ever upon public perception, continues to fight its corner through spin and sound-bite. This makes it important that doctors communicate with the public in a manner that cuts through government rhetoric, to explain how part of the huge financial investment in the NHS is being squandered. In particular, the myth that MTAS is merely a hiccup in an otherwise well thought-out, sensible program of reform—MMC (Modernising Medical Careers)—cannot go unchallenged. With this in mind, we present some of the more prominent myths that continue to abound regarding MTAS and MMC.

MYTH ONE: DOCTORS AND THEIR LEADERS AGREED TO THE DEVELOPMENT OF MMC AND MTAS

A popular government defence of the MMC and MTAS process is that their development was supported by doctors and their leaders:

‘ ... we have worked closely with the Academy of Royal Medical Colleges, the BMA, NHS Employers and others over a long period.’ (Andrew Burnham, Health Minister, 24 April 2007)⁵

Sadly, there is a continuing failure to acknowledge the multiple occasions on which both the Royal Colleges and the BMA have questioned the timing and implementation of the process. In their letter to the Lancet, the Presidents of the Royal College of Physicians and Royal College of Surgeons reported that:

‘... the genesis of MMC and the Medical Training Application Service (MTAS) has been complex and the final products far away from the principles of “Unfinished Business”.’⁶

Even more damning is the Royal College of Physicians' assertion that this is:

‘the worst episode in the history of medical training in the UK in living memory.’⁷

There are many tough challenges ahead, but issues such as the disempowerment of the Royal Colleges with the institution of the government quango PMETB, and in particular the wider concern of excessive central control and deprofessionalization of doctors should provoke apprehension in all within medicine.

MYTH TWO: DOCTORS DO NOT WANT COMPETITION

That junior doctors are anti-competitive has increasingly become the government mantra in recent weeks. What better way to denigrate objectors' concerns than to invoke an elitist, haughty stereotype, convinced of its right to unimpeded progression? Yet of all the government's arguments this stands out most blatantly as a straw man fallacy: no doctor would expect that job applications would be uncompetitive; indeed the lives of doctors are, from their schooldays, characterized by intense competition. It is the nature of the competition that is in question. Few would argue that the previous system was perfect, or that some minor, well-considered reform was not appropriate; but the previous system was largely meritocratic and, most importantly, produced very good doctors, a point even the Secretary of State for Health seems to agree with:

‘(This house) recognises the international reputation for excellence of medical training in the UK.’ (Patricia Hewitt, Secretary of State for Health, 24 April 2007)⁷

It was competition in the medical profession that led to the so-called ‘lost tribe’ of Senior House Officers and the subsequent development of MMC. However, the proposed solution to this problem will only serve to create a new ‘lost tribe’ of juniors consisting of those unable to secure one of the limited number of training posts or considered too experienced to apply for training posts, such as those undertaking higher degrees. In the past we could choose to be ‘lost’ in the pursuit of excellence either via research or a broader clinical experience prior to specialization, and it was these experiences which helped develop important—though less measurable—qualities of a good doctor.

MYTH THREE: NO DOCTORS WILL BE UNEMPLOYED IN AUGUST

The government has denied that there will be significant unemployment amongst doctors come August. Yet a leaked document from NHS Employers⁸ investigating whether doctors could do volunteer work overseas seems to suggest that, in at least some parts of the Department of Health, concerns have been raised. With so many different numbers floated regarding training posts—figures propped up by the inclusion of fixed term specialist training appointments—it has been difficult to escape the impression of obfuscation by the DoH when, astoundingly, nobody seems sure how many expensively trained, dedicated and capable young doctors will actually be without a job.⁹

MYTH FOUR: THE COMPETENCY-BASED TRAINING SYSTEM OF MMC WILL IMPROVE THE QUALITY OF DOCTORS

It seems self-evident that measuring how ‘competent’ a doctor is allows poorly-performing doctors to be identified and makes sure that all doctors achieve a certain standard. Of course, what constitutes a ‘competent’ doctor, how this is best measured, and indeed whether it can be measured, remain entirely different questions. The unvalidated competencies doctors must achieve under MMC, though important, tend to be simplistic things that are easily measured (e.g. the ability to take blood). Are the more complex aspects of what makes a good doctor to be disregarded because they cannot easily be measured? Those less tangible aspects—such as experience, intuition, sound professional judgement, the ability to establish rapport with patients and, perhaps most importantly, caring—are difficult to measure, but historically have been assessed by close, experienced senior colleagues; again, largely successfully. They allow a distinction to be drawn between a very good doctor and merely a competent one, unlike the alternative which tells us only whether a doctor has acquired basic skills or not. The role of the tried and tested Royal College examinations is also being eroded. Furthermore, it seems ludicrous to suggest that decreasing the number of years taken to train doctors to a ‘competent’ ‘consultant’ level can be consistent with the reduced hours of training that have resulted from the European Working Time Directive.

MYTH FIVE: MMC IS ABOUT IMPROVING PATIENT CARE

The government has been keen to stress throughout both the MMC and MTAS fiascos that one of the central aims of implementing change was to improve patient care. It is perhaps surprising, then, how few people with experience of medical training believe that this will occur.¹ Perhaps the most pressing issue is what will happen in the first week of August. Will we see the largest ever changeover of doctors over a couple of days, or a failure to recruit people in time, resulting in hugely understaffed medical teams? Neither seems an acceptable option for patient care and safety. Yet the government continues to seek to dissociate itself from this disaster waiting to happen, putting the onus instead on individual Trusts:

‘Each hospital Trust, and the board of each Trust, has a responsibility to its patients to ensure that on 1 August, or any other day, the right number of the right staff are available to provide safe, high quality care.’ (Patricia Hewitt, Secretary of State for Health, 24 April 2007)¹⁰

But as one consultant has stated in a letter to MPs:

‘Trust CEs and MDs are deceiving themselves if they believe that MTAS can now deliver a full complement of Juniors to their workforce on August 1st.’¹¹

The clear outcome of MMC and MTAS is to have politicized an entire generation of doctors. More tragically, they risk stifling the vocation of young professionals who, as enthusiastic, ambitious and caring as their predecessors ever were, are faced with unemployment, emigration, or at best a shorter, inferior training experience. There are solutions to this problem, but they do not lie in a doctrinaire DoH championing an arbitrary, iniquitous, unvalidated application process. Perhaps a short bridging period where only non-training posts are awarded would allow service provision while a fair application process is developed. It is important, however, that the delay before any new process is implemented be minimized—junior doctors and the public deserve better.

It seems clear that we cannot remain apolitical when it comes to government health policy. That doctors have found a voice so quickly is due not only to the strength of feeling, but also to the work of Remedy UK, the fledgling group of junior doctors who have so successfully organized the opposition to MMC/MTAS through the march, parliamentary lobby and judicial review. We must unite as doctors to send a clear message to the new Prime Minister and his government: we want to provide the best care for patients that we possibly can, and MMC in its present guise will not allow us to do so.