The future of specialist training
Authors: Fiona Godlee
Journal: BMJ (2007)

The United Kingdom's doctors are for once united, but not for the moment under the auspices of the BMA, their trade union and professional body. Instead, their growing outrage about new rules for junior doctors' specialist training has found its voice through two pressure groups, while the chairman of the BMA's council has been forced to resign for failing to reflect members' views. RemedyUK's legal challenge—due to conclude after the BMJ goes to press—is likely (even if they lose their case) to force a rethink of the way in which training posts are filled, while surveys of doctors run by an ad hoc group of senior academics under the leadership of Morris Brown (see bmj.com) have brought consultants and junior doctors together in a rare show of solidarity.

Jim Johnson's unprecedented resignation, weeks before the organisation's annual meeting at which he planned to stand down, bears further witness to the depth of feeling across the profession and within the BMA. Anger about the Medical Training Application System (MTAS) may have been the touch paper that set off this immediate crisis, but it has its roots in the new specialty training scheme Modernising Medical Careers. The scheme is based on sound and broadly agreed principles—longer contracts offering greater security, competency based training, and more senior supervision—but the manner of its implementation was condemned by the BMA and the colleges, and it led to the resignation last month of Alan Crockard. Radically shorter, narrower, less flexible, and less personalised training was aggravated by a rushed and centralised implementation, a rigid and ultimately unfit application system, and a considerable shortfall in the number of training posts. Ignoring advice from the various professional bodies, the Modernising Medical Careers team went for a big bang implementation, not only for new entrants to specialist training but for those already in training posts. The system was not piloted, its ability to discriminate between good and less good candidates was not validated, and (as revealed in RemedyUK's judicial review) the software was neither finished nor tested before it was put in place.

Among the hundreds of postings to medical and newspaper websites in the past few weeks are many proposals for rescue from the immediate crisis, some of them more feasible than others. RemedyUK's position, initially calling for the whole system to be scrapped, is now to honour job offers but only as temporary appointments that will not count towards specialist training. Morris Brown's position is that the temporary appointments should be retrospectively accredited towards training. While both groups have touched a nerve and given the BMA a master class in how to mobilise members, neither are representative bodies that can be held to account. The BMA is. Its junior doctors' conference did not support temporary posts, taking the view that most candidates are likely to be accommodated through further iterations of round one and extended provision of interviews and posts in round two.

No one doubts that this is an enormous mess for which the government and the chief medical officer have yet to stand accountable. We will know more about where to apportion blame when John Took's independent review reports at the end of the year. Meanwhile, the profession as a whole has suffered a hard knock from which its leaders are clearly keen to learn. Most people I have spoken to acknowledge that the BMA has let down junior doctors. They also feel that the organisation needs to modernise, that it needs to find better ways to stay in touch with its members, and that it needs to find a better balance between representation and leadership and between working with government while remaining strongly independent of it. Failure could put at risk the BMA's official monopoly on representing the UK's doctors. The threat of mass resignations by junior doctors confirms that this is a position the BMA needs continuously to earn.

Now is the time for the profession to unite. We need a comprehensive rethink, a chance perhaps to put this miserable episode to good use. We need solutions for the immediate problem, including a better understanding of how many additional posts are needed and how these can be filled with the best candidates. All parties then need to work together—the BMA, the colleges, government, and groups like RemedyUK—to design and pilot a specialist training scheme fit for the future of health care in the UK.