MMC Inquiry – Professor Sir John Tooke

1. MMC Inquiry – Professor Sir John Tooke RCP London Open Forum 29/05/07

2. MMC Inquiry - methodology • An inquiry into MMC not just MTAS • On –Line Consultation open to all www.mmcinquiry.org.uk • Written and oral evidence from stakeholders • Draft report to be published for consultation in September • Final Report to be published in December

3. MMC Inquiry Terms of reference (abridged) • The extent to which MMC has engaged with the profession • The extent to which the implementation date has met the needs of trainees etc • The governance structures underpinning MMC • Implementation including selection and recruitment • Impact of the wider professional, workforce and service environment on the programme

4. MMC Inquiry – specific issues raised by stakeholders • Effective engagement with the profession • Appropriate relationship between the acquisition of competence and the pursuit of excellence • Assessment methodologies used in selection • The use of Assessment centres • The level of choice on offer at application

5. MMC Inquiry – specific issues raised by stakeholders (2) • Lack of flexibility of run-through programmes • The role of FTSTA posts • Relative roles of Deans/Colleges in Programme delivery • Need for flexible implementation across the UK

6. MMC Inquiry – Panel Members • Prof Sir John Tooke • Sue Ashtiany • Sir David Carter • Dr Allen Cole • Sir Jonathon Michael • Prof Aly Rashid • Prof Peter Smith • Prof Stephen Tomlinson

7. MMC InquiryInitial Questions to Colleges • What is your College’s view of MMC and the principles that underpin it? • What amendments would your college like to see to facilitate the best possible specialist training in the UK? • In what practical way would your constituency best contribute to that process?

8. Draft RCP Response (1) Selection and Recruitment • Any new process must be piloted • We support a national application process but for 2008 selection should be at deanery level to allow time for pilots etc • An “exam” similar to that used by GPs might provide a useful ranking for short listing • “White Box” competencies should be assessed – but perhaps most appropriately at interview. • Clinical experience and academic performance should be appropriately weighted • Alternatives to the simultaneous annual appointment round should be considered

9. Draft RCP Response(2) MMC Implementation • Flexibility and Duration of training are key issues • We wish to restore the flexibility of career pathways envisaged in the early iterations of MMC • This could be achieved by de-coupling Core Medical Training from Higher Medical Training so that run-through for Physicians begins at ST3 • We should be more flexible about the duration of CMT programmes

10. Why de- couple CMT and HMT? • Current selection tools are inadequate for “high stakes” selection out of F2 • De- coupling allows FTSTAs equal access to ST3 – this allows us to deal with both “late developers” and “poor performers” in the CMT cohort. • De-coupling gives access to training in Medicine to potential Radiologists, GPs etc • De- coupling may make access to useful experience “out of programme” easier

11. MMC implementation • We should take the opportunity of reviewing the appropriateness of MMC structures for Flexible Training and Academic Training

12. MTAS – Phoenix from the Flames Sarah Thomas Postgraduate Dean

14. Overview • MMC and MTAS • Policy • Lessons • Next steps

15. MMC and MTAS • MMC overarching broad initiative -CMO • New curricula • Run-through training • Competency –based, not time served • Early selection

16. MTAS • Electronic portal • Coordinated timetable for recruitment • National standards • Local deanery/specialty selection

17. External factors • PMETB • Legal and HR • Devolved Administrations UK policy • Global recruitment • Workforce planning • Service needs • 5 years SHO into ST1 and ST2 • Timescale

18. Current position • > 40,000 interviews 1a • Appointability average 75% all specialties • >17,000 interviews 1b • Transition plan • Judicial review • 80%filling • Round 2 • Applicant support package

21. Lessons • High volume system requires consistency • Implementation has been variable • Governance • Resources • Timescale

22. Next steps • Constructive Review • Transition arrangements • Political issues • Revision for 2008

24. MTAS – what are we left with? Royal College of Physicians May 30th 2007Dr Judy King MRCPRemedyUK National Coordinator www.remedyuk.org

25. Introduction • Background to Remedy • Who we are • Aims and objectives • Campaigns and action points • MTAS – what are we left with • MMC • The next steps • Questions

26. Who we are: Mat Shaw Orthopaedic SpR, Stanmore Matt Jameson-Evans Orthopaedic Clinical Fellow, Stanmore Judy King Clinical Research Fellow, Royal Free Hospital Louise Bayne CEO Ovacome Chris McCullough Renal SpR, Royal Free Hospital

27. The problem: reforms are rushed, unfair and unsafe Immediate • MTAS: unfit for purpose Short term • 32,000 doctors applying for 20,000 posts: shortfall of 12,000 • “best and brightest” lost to the NHS • Lack of information at every stage – how will MMC work? • Reduction in standards under MMC (e.g. Orthopaedics: 22,000 hours versus 6,000 hours under MMC) • Concerns regarding single entry per year/patient safety on August 1st changeover Long term • No job security (sub consultant grade) • 200 excess SpRs this year - 3,200 SpRs without Consultant posts by 2010-11 • Medical school intake has not been reduced

28. Aims and objectives 1a. Halt Round 1/revert to old appointments system 1b. Appoint LATs 2. Expansion of training posts 3. Independent review of workforce planning (including review of medical school intake) These objectives would be achieved through: • Information campaign (Website, emails, newsletters, local reps) 2. Press campaign • Political campaign • Action

29. March on March 17th

30. Political campaign Jan ‘07: • Meeting with Dr Ian Gibson MP (Labour) of the Commons Health Select Committee • Tabled Early Day Motion 737 (130 signatures) • Letter writing campaign March ‘07: • Briefed both Shadow Health Secretaries • Briefing meeting with MPs • Ongoing parliamentary questions April ‘07: Rally at House of Commons Mass Lobby of 200 MPs

31. Westminster Rally & Mass Lobby of Parliament April 24th 2007

32. Judicial Review: 17th May 2007 • Justice Goldring concluded that “the premature introduction of MTAS has had disastrous consequences” • acknowledged that doctors had been treated unfairly and had reason to feel aggrieved • However, he felt powerless to intervene in the context of a judicial review • Suggested that there would be a good case for individuals at employment tribunal Sympathetic media coverage Evidence from the trial that has come to light: Round 1a and 1b were very different Correlation between shortlisting and interview scores: 0.3 Matching algorithm was abandoned because it didn’t produce the expected results and hadn’t been tested Process overall tended to work better in smaller UoAs.

33. Software needs to be validated, tested and reliable Pilot Shortlisting criteria validated Secure system Need clear guidance on who to ask for help Smaller UoAs More than one entry point (e.g. August and Feb) per year MTAS – what are we left with?

34. What about MMC? Change from experience based to competency based training What if competencies aren’t achieved? What about Royal College exams? Run through training following Foundation Years 1 & 2 Too early for trainees to make career decisions? Too early to differentiate between candidates? What if you change your mind/want to work abroad/undertake research? Flexibility: separate CMT from HMT? Reduced time taken to complete specialist training Orthopaedic trainees: 22,000 hours training under the old system vs 6,000 under MMC

35. “How will reduced doctors’ training time impact on patient care?”

36. The next steps Support for juniors. Career advice. Information Article 14 (www.pmetb.org.uk) Ongoing issues of workforce planning, sub-consultant grade, etc, to be addressed • Learn to consult and communicate more effectively (website/email) • RCP Open Forum • RCS poll of members and fellows • Change in the landscape Encourage a more active role – Royal Colleges, BMA, Remedy, RSM Sir John Tooke’s review

37. Only those who speak up will be heard http://e-consultation.net/MMCInquiry www.remedyuk.org Be part of the solution

38. The importance of MRCP in run-through training Jane Tighe Chairman MRCP(UK) Part 2 Examining Board

39. QA and Assessment - The 9 Principles of PMETB • The system must be fit for a range of purposes • Curriculum based & referenced to good medical practice • Methods used relevant to the assessment framework • Standard setting must be in the public domain • Assessments must provide relevant feedback • Assessors trained for performing tasks they undertake • Lay input in the development of assessment • Standardised documents nationally and internationally • Resources sufficient to support assessment

40. Academy of Medical Royal Colleges: categorisation of assessments • Group 1: assessments of performance – especially in the workplace (what the trainee does or has done in real life) • Group 2: written cognitive assessments e.g. of knowledge or aptitude • Group 3: assessments of competence in face-to-face, simulated or OSCE-like settings

41. MRCP(UK) Examinations • Part 1 Examination • 2 papers; 100 items per paper • Best of five format • Criterion referenced • Tests basic medical knowledge (of common medical conditions), basic clinical science • Uses evidence-based medicine and tests up-to-date knowledge

42. MRCP(UK) Examinations • Part 2 Examination • 3 papers; 90 items per paper • Best of five format • Criterion referenced • Tests the application of medical knowledge, clinical reasoning and prioritisation of investigations and treatments • Mapped extensively to curriculum for general medical training

43. MRCP(UK) Examinations • Part 1 • Set at a level appropriate for graduates of 2 years • Part 2 • Ensures satisfactory standard of knowledge across wide range of medical specialties, to provide essential basis to specialisation • Aimed at graduate of 3 years, prior to specialisation ideally

44. Integration of UK Royal Colleges’ Examinations into training CCT Specialty Credential in Acute & Internal Medicine Specialty Training Curriculum ACUTE & INTERNAL MEDICINE Level 1 (CMT 1 & 2) Foundation F 1 & 2 ACUTE & INTERNAL MEDICINE Levels 2&3 (ST 3 +) Generic Curriculum for Medical Specialties WPBA WPBA WPBA Allocation Selection

45. Royal Colleges’ Examinations Independent national standard Criterion referenced Complementary to local formative assessments Summative tests Often Pass/Fail Test large part of curriculum Work based assessments On site Multiple formats to suit different challenges Mini-CEX involves local clinicians Instant feedback Competency based Tests limited parts of curriculum Integration of the UK Royal Colleges’ Examinations into “Post MMC” Training

46. Independent Assessments: group 2 and 3 Diploma Examinations of the UK Royal Colleges • 4 modules • MRCGP • 3 part diplomas • MRCP(UK) • MRCPCH • MRCS • 2 part diplomas • Anaesthetics • Psychiatry • Pathology

47. MRCP(UK) Examination objectives Evaluates competence with regard to: • Core clinical knowledge: problem solving,clinical science, epidemiology, statistics • Clinical skills: taking and interpreting a clinical history and undertaking a physical examination • Attitudes: to patients, including communication skills and ethical obligations Stimulates approach to long term learning/CPD

48. Examinations of the UK Royal Medical Colleges must be: relevant reliable reproducible realistic

49. Training in Medicine:Positioning of MRCP(UK) Part 1 CCT Specialty MRCP(UK) Credential in Acute & Internal Medicine Foundation F 1 & 2 ACUTE & INTERNAL MEDICINE Level 1 (CMT 1 & 2) Specialty Training Curriculum ACUTE & INTERNAL MEDICINE Levels 2&3 (ST 3 +) Generic Curriculum for Medical Specialties WPBA WPBA WPBA Allocation Selection

50. MRCP(UK) pass rates for UK graduates