The British Geriatrics Society

The British Geriatrics Society (BGS) is the only professional association, in the United Kingdom , for doctors practising geriatric medicine. The 2,200 members worldwide are consultants in geriatric medicine, the psychiatry of old age, public health medicine, general practitioners, allied health professionals, and scientists engaged in the research of age-related disease. The Society offers specialist medical expertise in the whole range of health care needs of older people, from acute hospital care to high quality long-term care in the community.

Geriatric Medicine
Geriatric Medicine (Geriatrics) is that branch of general medicine concerned with the clinical, preventive, remedial and social aspects of illness of older people. Their high morbidity rates, different patterns of disease presentation, slower response to treatment and requirements for social support, call for special medical skills. The purpose is to restore an ill and disabled person to a level of maximum ability and, wherever possible, return the person to an independent life at home.

The Society is delighted to be given the opportunity to contribute to this debate and would comment as follows:

What are the principles underlying MMC and are they sound?

The Society fully supports many of the underlying principles. It is the implementation of new structures, the unrealistic timescales and the lack of inclusion of those most closely involved in delivering training that has caused most concern.

The Society strongly recommends that training of the medical workforce should:

• Occur in well-structured, managed, time-limited programmes, based on clear curricula, driven by educational objectives
• Be supported by a robust framework of educational supervision (requires trained consultant staff with dedicated time to undertake this)
• Include communication skills as a vital aspect
• Include effective team working as a vital aspect
• Reflect the predicted needs of an ageing population
• Be sufficiently flexible to accommodate a) changes in career choice, b) out of programme experience for research and other academic activities c) less than full time working at all grades

There needs to be closer cooperation between deaneries, colleges, faculties and PMETB to allow a clear allocation of responsibilities for different parts of assessment. This is not straightforward with so many parties involved.

To what extent the practical implementation of MMC has been consistent with the programme’s underlying principles.

• Progress has been made with curricula and measureable educational objectives. We strongly support the move towards validated assessment methods but there is still some way to go. It will take time to develop these properly and implementation will require significant support if they are to be meaningful.
• However, it is clearly impossible to assess all aspects of the curricula. In addition, many important decisions in clinical medicine are judgement-based, strongly dependent on experience. There are considerable concerns that the reduction in training time (imposed by both the working time directive plus MMC) reduces opportunities for repeated exposure to clinical scenarios. The emphasis in MMC seems to be to gain a superficial breadth of exposure to a number of areas. This is not the same as acquiring a secure set of broad skills and the experience required to make sound judgements.
• The eportfolio/log book is insufficiently developed to be used as an assessment tool in the first run of MMC and to compare trainees from different deaneries.
• communication skills and effective team working have always been promoted within geriatric medicine and we welcome the new emphasis on these skills across the other specialties
• we remain concerned that the changes in training are insufficiently linked to the workforce required to care for an ageing population. There are two components to this: a) Numbers of geriatricians will need to increase as more “Expert generalists” will be required b) most other specialists (including GPs, Radiologists, Anaesthetists) will require some training in the principles of care for older people. Opportunities to gain a breadth of experience in core medical training for these groups have been reduced by the shortened and restricted new career structures.

3. The strengths and weaknesses of the MTAS process.

Strengths

A national online application system has considerable merit and could potentially be more efficient than previous systems.

Weaknesses

1. MTAS was not adequately piloted and was far too immature to be nationally adopted. Computer system was unfit for purpose. Adequate time to develop a robust and acceptable system is required.
2. Application system was fundamentally flawed – “reductionist approach”. Many of the sections were open to plagiarism and copying. Many sections could only be assessed by face to face interview.
3. “One size fits all” concept inappropriate when trying to select for such a wide range of specialties. Insufficiently discriminating for the individual specialties.

Although this type of application system had done well in General Practice, this is just one specialty.

1. Short-listing process was insensitive and invalid. Many reports of trainees who were not short-listed first time round then doing very well at interview and vice versa.
2. Scoring system insensitive eg common problem was joint scores, no agreed process as to how to manage this. Often random selection.
3. Scoring system failed to adequately reward academic achievements and experience.
4. Lack of sophistication re allocation of interview dates. Reports of trainees being called for three sets of interviews in different regions on the same day.
5. The issue of national vs deanery selection for training needs to be explored further. There needs to be close working across deaneries to allow flexibility for individual trainees who wish to move around the UK .
6. One appointment round per annum will be insufficient

4. What lessons about project management should the Department of Health learn from the failings in the implementation of MMC.

The views of trainees and those most directly involved in training should underpin any reworking of the application system.

Major changes in medical training should be implemented over a realistic timeframe. The timescales set to implement MMC (and especially MTAS) were completely unrealistic and was one of the fundamental flaws of the process.

Rigorous piloting of any proposed changes should occur before universal implementation.

5. The extent to which MMC has taken account of the supply and demand of junior doctors and the number of international medical graduates eligible for training in the UK.

There is a lack of robust data regarding numbers of graduates UK / EU / IMGs eligible for training.

In addition, the basis of the calculations for numbers of run through specialty training posts is unclear and appears to be inaccurate – ie inadequately reflects the demand for service requirements. Numbers for England , Scotland and Wales have been calculated differently.

This type of data is central to workforce planning and to give realistic career guidance (students and qualified doctors)

At the last round most trainees (and educational supervisors) had little or no idea of their chances of achieving run-through training and CCT or conversely the proportion of trainees likely to enter “career posts”. There appears to be a lack of basic accurate data on the number of CMT or FTSTA posts in the system. At the last round more posts were suddenly “created”.

There appears to be a particular shortfall in numbers of run-through training programmes in hospital medicine.

There needs to be an explicit calculation of numbers, based on the service requirements of a changing/ageing population eg the predicted increase in numbers of older people will require doctors trained in geriatric medicine and most other specialists will require some training in the principles of care of older people. However, the reality is that the workforce is being dictated by the ever- changing whims of local PCTs/LHBs. It is not linked to a central strategy regarding care of older people. Hence the “workforce re-profiling” that is much mentioned in terms of government`s plans is unlikely to be realised via MMC.

6. The degree to which current plans for MMC will help to increase the flexibility of the medical workforce.

Although flexibility is a stated aim of MMC, the reality appears to be a move towards less flexibility eg.

• Commitment to specialty occurs too early. The concept of run-through from ST1 fails to recognise the importance of a varied and broad training.
• Opportunities to move between specialties are severely limited. We know from previous surveys that doctors frequently change career direction.
• Reduced opportunities to gain breadth of experience in core medical training - important in Geriatric Medicine where we are training “Expert Generalists”
• Loss of opportunities for those outside medical specialties to access core training in medicine eg general practice, radiology, anaesthetics. This may negatively impact on the management of older people who are the most frequent users of such services.
• Out of programme experience at all levels is less easy to set up and more complex. This is a particular disincentive to research.
• Rule book is perceived as being too complex

7. The roles of the Department of Health, Strategic Health Authorities, the Deaneries, the Royal Colleges and the Postgraduate Medical Education and Training Board in designing and implementing MMC.

No acknowledgement that the new system will involve additional work for the current consultant workforce. Dedicated time is required within consultant jobplans for

• Selection of trainees
• Educational supervision
• Assessments
• Appraisal
• Career Counselling
• Additional clinical work that less experienced trainees and newly qualified consultants will be unable to take on.

A consultant may have to supervise at least 3 trainees at any one time (FP1, FP2, CMT, Specialty Trainees) as well as non medical staff (eg Nurses, Pharmacists).

Trusts (and some Deaneries) appear to be oblivious to the implications of this newly created work. Many members of the Society report that there is no recognition for this work within individual jobplans (SPAs are being driven down). Educational Supervision is therefore either not done or will be poorly done (which defeats the object of delivering quality assurance) or it is undertaken in personal time (not sustainable). There is a growing frustration and a degree of demoralisation within the consultant body because of the time pressures to achieve Trust targets none of which are directly linked to delivering a training system as set out in MMC. This tension needs to be addressed.

To date there appears to have been no significant discussion between those involved in MMC, the Departments of Health (all nations) and those delivering services (Trusts and Heath Authorities), regarding the impact on Consultant time and hence service delivery. Needs to be far more joined up.

The Royal Colleges appear to have maintained a role in development of curricula and assessment methodologies. However there is considerable concern that there has been a loss of quality assurance/control of training programmes following the cessation of external college visits. New system is too broad brush to identify and deal with the complex and sensitive specialty training issues that arise. There are specific examples within our specialty where this has proven to be the case and we understand other specialties are in a similar position.

MMC, MTAS and PMETB should recognise the experience and competence of senior specialists in the processes of quality assurance and assessment of trainees. This is provided through the SACs and Educational Committees of Specialist Societies.

Professor Peter Crome MD PhD FRCP FFPM
President
For and on behalf of British Geriatrics Society
16 October 2007