Centralised application services for specialist training
Authors: Tony Delamothe
Journal: BMJ (2007)

This week marks the end of round one of the UK's scheme to fill specialty training posts that become available in August. All applicants have been offered the opportunity of at least one job interview, and those who have not been offered a job can apply for any unfilled posts in round two. For this second round, however, local deaneries will manage the process. The Medical Training Application Service (MTAS), whose premature and poorly implemented introduction was condemned by a judge for its “disastrous consequences,”1 has been shelved.

Good riddance, chorus Britain's doctors, but the decision brings little comfort to the thousands of demoralised juniors still caught up in the uncertainties and frustrations of finding a job. While assessing the ongoing fallout of MTAS, it's salutary to be reminded that other countries have pulled off what looks from Britain like an impossible feat. In this week's journal, Tony Jefferis reports that “a central application portal with local selection . . . has been used successfully in the United States, Canada, and, in a modified form in Australia and New Zealand for at least 30 years.” And these countries have successfully negotiated, or are negotiating, the transition to computerisation.2

What can Britain learn from their example? Jefferis found that other countries' matching schemes “are all efficient, have clear time tables, and are consistent from year to year.” Candidates have time “to make informed choices and to compile their application.”

Britain's year one was always going to be tough, but many things made it tougher, in ways that those responsible for its implementation should have predicted. Computer crashes and security breaches are par for the course for the United Kingdom's public sector information technology projects, few of which deliver on time, on budget, and to specification.3 By opting for a “big bang” approach—including all training jobs, at all levels, in all geographical areas—the system was maximally stressed. An added complication was that while the senior house officer (SHO) grade is disappearing overnight, the many doctors filling such posts aren't, and nor are the service needs they have been fulfilling.

The breakneck speed with which the changes were introduced just about overwhelmed the human resources needed to process the applications. The need to build in flexibility was sacrificed to getting the scheme off the ground. Many juniors, and those who should have been advising them, did not appreciate the scale of cultural change and how qualitatively different the new selection process was going to be. Understanding—let alone “buy in”—was lacking.

The next substantial criticism of the new system was that it was a poor discriminator of applicants. (The “evidence” for this is the large numbers of “high flyers” without job offers, a claim that will have to await the end of round two for proper substantiation.) The new application form was blamed for giving precedence to free text answers about competency over evidence of clinical experience.4 Its masking of medical school and country of training—an attempt to reduce discrimination—was seized on as a weakness rather than a strength.

The countries that Jefferis analysed do things the way Britain used to. All have application forms covering undergraduate and graduate training, honours and prizes, research and publications, and extracurricular and community activity. To help in selection, all four countries use reports and references—from medical school deans, referees, supervisors, and the like (some solicited by telephone). Programme directors rank candidates in order of preference using the application form, references, and interview. Candidates' preferences and those of the programmes are then matched centrally, “without controversy.” Jefferis doesn't explore how these systems protect candidates from selectors' biases towards “people like us,”5 which was a laudable aim of the UK's proposals.

The remaining serious criticism of MTAS was that it would leave 12 000 junior doctors jobless from August, which no amount of tweaking with computer programs or application forms would have altered. A large proportion of the “excess” applicants are thought to be doctors trained overseas—including some working in non-training grade trust posts, some doing unpaid observerships or locums as they try to get substantive appointments, and others currently overseas. Jefferis found that the countries he looked at avoided these problems—while international graduates made up an integral part of their medical workforce their applications were considered only after those of domestic graduates.

John Tookes's inquiry into the UK's specialty training scheme, Modernising Medical Careers, is looking much more widely than merely “the mechanics of the process,” although it is hard to imagine this won't consume a lot of its attention, given the shortfalls of the discredited system. In its current consultation phase the inquiry wants to explore “alternative solutions, grounded in evidence.” Jefferis's article shows that a scheme that combines central computerised application with local selection is not necessarily an impossible dream.


Why the numbers didn't add up
Last year's Postgraduate Medical Education and Training Board survey indicated that there were 17 500 SHOs in educationally approved posts in the UK. Posts available for MTAS recruitment were estimated at 18 500, not including posts filled by general practitioner trainees. In total, the UK had around 23 000 posts at SHO level—so plenty to go round. But there was also an unknown number of trust grade doctors and doctors outside the UK with, or eligible for, General Medical Council registration. In total, 34 000 doctors applied, hugely in excess of the SHO population for whom the posts were intended.

Until last year, international medical graduates appointed to training posts were given permit-free training visas. Without warning, the government announced last year that this scheme was withdrawn. Doctors without right of residence could work only if no suitable UK or European Union candidates had applied for the job and the employing trust could apply for a work permit using the “resident labour market test.” Meanwhile, such doctors could apply for permission to work through the highly skilled migrant programme. These doctors would be able to apply on an equal footing to UK citizens, but they would initially be granted a visa for only two years and would then need an extension. They would therefore not have a visa to cover the whole of the training programme, and the Department of Health recommended that they should not be eligible for training programmes longer than two years.

For the time being, however, these doctors have been granted equal eligibility to UK citizens and others with a right to work pending an appeal against a High Court judgment that restrictions on permit-free training were lawful. Thus, these doctors were included in the first round of application to MTAS and added to the excess of applicants.