Monday, 30 July 2007

Botched operation...

...and no one accepts the blame

Botched operation

There is still fury over the junior doctors appointment fiasco. But why? And how did the defective system get passed in the first place?

Sarah Hall
Wednesday July 25, 2007
The Guardian

When Sir Liam Donaldson, the chief medical officer, published his annual report last week, he found himself having to justify not resigning over the bungled junior doctors' appointments system. "The implementation in some respects went wrong," he conceded. "But the responsibility was very widely distributed."

His justification, coupled with an apology, followed widespread denunciation of the system by delegates at the British Medical Association's (BMA) annual conference last month. A motion calling for his resignation was overwhelmingly passed, while the BMA's then acting chairman, Sam Everington, condemned the "scandal" of thousands of doctors contemplating leaving medicine or going abroad.

The sustained level of anger may surprise those outside the profession who thought the medical training application system (Mtas) fiasco was resolved in March, when the then health secretary, Patricia Hewitt, announced that it was being abandoned in its current form and promised every junior doctor an interview in their first-choice area. Mtas had been problematic because the unpiloted computer system, which aimed to appoint junior doctors centrally, was deeply flawed, with problems such as application forms giving too much weight to "creative writing" and too little to academic achievements and clinical experience, and too little consistency to the shortlisting process.

But junior doctors, and their senior colleagues, remain angry and unhappy about the debacle. One in five juniors affected is feeling increasingly suicidal and 94% have felt higher stress levels during the six months covering the application and interview process, according to research published in the British Medical Journal online. Hospitals have been told to be on suicide alert.

Much of this fury is due to the mismatch between training posts and applicants, and the uncertainty this is causing. Department of Health (DH) figures reveal that doctors are chasing 18,391 training posts - with 29,193 applying for 15,600 in England. A total of 2,320 posts will be on offer in a second round of applications, but at least 12,000 eligible junior doctors will remain without posts and will instead have to seek work abroad, leave medicine, or remain in staff-grade jobs, which will not allow them to become consultants and are often seen as career dead-ends.

The problem is most intense for the more senior doctors in the most competitive areas of surgery: figures released by the DH earlier this month show that 713 orthopaedic surgeons, 885 general surgeons, and 206 plastic surgeons were without training posts at the end of round one. For would-be surgeons, the chances of getting a training post are as slim as one in five for general surgery, or one in six for orthopaedics.

Doctors are also angry that, with most jobs supposed to start on August 1, they face a scramble to apply for the remaining training posts available in round two, or for vacant non-career jobs.

The second round of interviews has been extended to the end of October, and every junior doctor still applying is supposed to be guaranteed employment until that deadline. But there are no promises that this will be in their existing hospital, or even in their existing trust.

Huge uncertainty has surrounded even those who have received jobs, with successful applicants only recently being told in which hospitals they would start. With deaneries such as London covering all of Greater London, Kent, Surrey and Sussex, and the East of England deanery covering Essex, Suffolk, Cambridgeshire and Norfolk, huge logistical problems have been arisen in terms of arranging accommodation and childcare.

Childcare problems

The profession wants to retain women, who now account for 60% of those entering the profession, but they are being forced to abandon their careers to keep their families together or because of childcare problems.

Andrea Siggers, a GP with a one-year-old son, has had to give up her job because her husband was unable to gain a training post in emergency medicine in Wessex, but gained one in the south-west. And Katharine Augustine is having to move to Southampton, with her 19-month-old son, to pursue a training post in radiology, while her husband takes up his cardiology post in Bristol. With a second baby due in January, she says: "There are no other job options, and I need to be in continuous employment to get maternity pay. This process is forcing apart many families."

Crucially, the ongoing fiasco will affect not just junior doctors but also patients. Morris Brown, professor of clinical pharmacology at Cambridge University, says it is unlikely hospitals will become "chaotic" at the start of August, but warns that clinics and elective surgery will be cancelled - with an obvious impact on waiting lists.

Brown, a leading critic of Mtas, is more concerned about the long-term impact on the quality of medical care and clinical research. A poll he is conducting suggests that the system, which gives the same weight to a PhD and to a two-day course that can be attended by paramedics, disadvantages the most academically able.

The relative absence of posts for the more senior junior doctors also means the experienced will be shunted into non-career posts, while inexperienced colleagues entering at a lower level will become the consultants of the future. That is compounded by the shortened training offered under modernising medical careers (MMC), the new system to which Mtas relates - and by the European working time directive, which, from 2009, will reduce junior doctors' hours to 48 a week.

Then there is the long-term impact on the NHS of a demoralised group of doctors, stuck in dead-end jobs, and no longer feeling a strong sense of vocation.

So how did this catastrophe in workforce planning happen? In part, because, with all applications for training under the old system drying up last autumn, an unprecedented number of doctors applied under Mtas. As Donaldson, the original architect of MMC, admits in his report: "The number of doctors ... was larger than anticipated."

The number of junior doctors had burgeoned since the NHS Plan enabled a rapid expansion to allow the NHS to meet new targets. But, with NHS deficits being felt from 2005, hospital trusts then began to cut back jobs and training posts.

Andrew Rowland, of the BMA's junior doctors committee, says that, when it came to MMC and Mtas, there was a lack of engagement between the bodies involved in workforce planning - individual trusts, deaneries, regions and individual specialities on a national level.

Richard Marks, programme director in anaesthetics for north-central London, says programme directors - the people with experience of the actual numbers needed for each region - were left out of the loop. "The hierarchy seemed to be that Lord [Norman] Warner [the health minister, who retired in December] wrote to the deaneries for numbers required, the deaneries asked the trusts, and trusts then told the programme directors - without anyone asking the departments what was needed." Strategists were planning 10 years ahead, but were not sufficiently engaged with the number of doctors currently in the system, he adds.

Meanwhile, it is these doctors, and their future patients, who will suffer.

· Sarah Hall, a Guardian senior reporter, is married to a junior doctor who is applying for jobs under round two of Mtas

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