'Junior doctor mayhem looms', screamed BMA News. Radio 4's Today had British Medical Association chairman Dr Hamish Meldrum denying he was shroud-waving as he warned the public that hospitals would be under immense stress with the change-over of all junior doctors.
There were similar stories across the national media in the run-up to 1 August. This was the day over 22,000 junior doctors took up new 'run-through' training posts in the NHS in the latest phase of Modernising Medical Careers.
They were doing so against a backdrop of uproar caused by the centralised, computerised Medical Training Application Service and a large over-supply of applicants.
To a casual reader, the case looked pretty open and shut. Thousands of highly - and expensively - trained doctors were being thrown on the scrap heap. Public safety was at risk.
Except for that niggling little inconvenience of the truth, which was rather more complicated. Come the day, it was far from mayhem in the NHS. Busy, certainly, but contingency plans were working thanks to the goodwill and hard work of managers, doctors and deanery staff.
The long and short of it was that on 1 August all but a handful of posts had been filled with high-calibre doctors or maintained by doctors whose contracts ended on 31 July but could remain in post until it was filled.
But after just a week, HSJ's sources in trusts, deaneries and at NHS Employers universally reported that although the process was undoubtedly stressful for the NHS and traumatic for the juniors concerned, the outcome was good.
Even the BMA graciously admitted the point in a letter to The Daily Telegraph. Consultants committee deputy chairman Dr Mark Porter wrote on 8 August: 'Last week, when thousands of doctors started new posts, the 'carnage' in hospitals predicted by some did not materialise. This is a tribute to them for getting on with their jobs in the face of the disastrous MMC implementation.'
'Was it a disaster?' asks a rhetorical Sian Thomas, deputy director of NHS Employers. 'This is obviously not the case because we have the best doctors from the 33,000 applications to the 22,000 posts. That's what is being reported back to us.'
True enough, not every doctor might be working in the location or post they wanted. 'And the big reason for that is there are more people wanting posts than there are jobs,' explains Ms Thomas. 'That's because we are working in a global recruitment market.'
Not only did NHS organisations get the best doctors, she says, but they also filled jobs in parts of the country and in specialties that previously did not attract candidates.
'On 2 August I got a phone call from a hospital in the East of England where for the first time ever they had filled all their posts,' says Ms Thomas. 'That's what you want to hear. This is a deprived area and people in these places need and deserve good doctors. That's not always been the case in the past when good doctors veered towards the elite teaching hospitals.'
Level playing field
North West postgraduate dean Professor Jackie Hayden chooses her words carefully: 'What MMC and MTAS has done is to encourage much more even distribution of applicants across the country.'
For that, read pathology posts filled in Cumbria, paediatrics in East Anglia or general practice in the West Midlands.
Professor Steve Field, head of workforce and regional postgraduate dean in the West Midlands, puts some of this down to the MMC reforms already in place (see box, opposite). 'We have been piloting the foundation framework for the last five years and have been able to show it is a success,' he says. 'One of the great things we did this year, and we are the first deanery to do it, was to put in place foundation-year posts in specialties we found it difficult to recruit to.'
These were general practice, pathology, psychiatry and haematology. The result is that foundation year doctors are choosing to go on to specialise in these areas.
'We have been delighted with the quality and quantity of applicants, many of them coming from our own foundation programmes,' says Professor Field. 'General practice is completely full with brilliant, brilliant doctors. A couple of years ago we were finding it difficult to recruit.'
Simply to say things went well this year is not really an adequate response to the uproar caused by MTAS, however. There is the legacy to deal with, both for the application process for next year and beyond and for MMC as a whole.
Many are looking to the MMC inquiry being led by Professor Sir John Tooke, ordered by former health secretary Patricia Hewitt, for answers. It finished taking evidence on 31 July, with over 300,000 items submitted via its website.
But as Ms Thomas points out, it will not produce an interim report until 20 September with its final report due in December. And by any stretch that is too late for next year's round. NHS Employers would like to see this finished by late May 2008, allowing trusts and doctors some foreknowledge of where they will be come 1 August. That means starting in November 2007.
'We have weeks and not months,' says Ms Thomas bluntly. There is no choice but to use MTAS next year, albeit with some significant improvements.
'Using MTAS for specialty training was not something employers supported, but we cannot design a new system in 12 weeks.'
Some changes have already been made, not least as a result of the Department of Health review of MTAS. But more needs to be done, as NHS Employers' evidence to the Tooke MMC inquiry spelt out.
One major failing of MTAS was to get senior human resources expertise on board. 'There is a tension for this group of people between the fact we are recruiting to a training programme, but they are also employees,' Ms Thomas explains.
'Fundamentally the employer is responsible for them, not the deanery, which is responsible for their training. So can it be right that the employers were not involved in the selection?'
Quite apart from that, HR professionals have knowledge of the global evidence base on selection procedures, including how to screen large numbers of applicants for eligibility.
Involvement is key
David Grantham, HR director at Whipps Cross University Hospital trust in London, adds: 'Employers feel they were not involved and that some of the problems could have been avoided if they had been. We have all come to the conclusion that these processes need to be much more clearly aligned between employers and the deaneries.'
HR input is now being taken on board nationally and locally. 'Now we have employers' representatives on the policy programme board that will publish what 2008 should look like,' says Ms Thomas.
Professor Field gives an example of improved joint working between his deanery and local trusts. 'We set up a board with our hospital, mental health and PCT to manage this phase. We have also had a very close working relationship with HR directors. The feedback through and to the service has been a massive benefit to the West Midlands health economy.'
As for the detail, NHS Employers wants to see online job advertising and national eligibility screening, followed by a locally managed process. Among the deans, the discussion is around transparency in the selection process and improvement in the application form.
The other issue that can be picked up rapidly for 2008 is that of international medical
The large number of overseas doctors applying for attractive UK training posts accounted for this year's oversupply of candidates. Some 30 per cent of junior doctors appointed to training posts are international medical graduates.
'There should be open competition so patients have the choice from the best doctors around the world,' says Ms Thomas. 'We also think higher-skilled migrant criteria need to be reviewed. Currently the definition is being a medical graduate of another country and this is not adequate.'
Longer lasting but also requiring immediate attention is damage to relationships with the medical profession, which has knock-on effects not just for 2008 but for confidence in MMC as a whole.
'Trainees' faith in the overall system has been badly damaged,' says Dr David Sowden, dean director of the East Midlands healthcare workforce deanery. 'Consultants are tired and not a little annoyed.'
He adds: 'We do not know how long this is going to last but there will be a balancing of attitudes in the next few months. Quite a lot will depend on what's planned for the next two years and the extent to which it's subjected to a positive response [from the BMA junior doctors committee].'
Whatever is done in 2008 must have the backing of consultants and junior doctors and the political commitment to stick with it, not a tendency to chop and change to appease pressure groups, Dr Sowden says.
The medium-term concern, meanwhile, is for MMC as a whole. Its principles are universally accepted as a good thing. From the chief medical officer through the deans and royal colleges, the BMA, NHS Employers and the British Association of Medical Managers, no-one wants to see the MMC baby thrown out with the MTAS bathwater.
'The problems with MTAS have fogged the good work being done by MMC as a whole,' says Professor Field in a comment that was repeated to HSJ in many forms.
NHS North East strategic head of workforce Dr Moira Livingston explains the background: 'The foundation programme started two years ago with equal concerns about recruitment and so on. Now we are seeing a highly successful programme.
'There is now a high level of satisfaction from employers. They provide high levels of patient care. The competence model and assessment is enhancing doctors' learning.'
Run-through training with its principles of a defined curriculum, competence-based training with assessment and defined outcomes should reap equal benefits, she says.
The trick for the Tooke inquiry will be to retain the good bits and improve the rest - realigning how MMC and medical training works with system reform and workforce planning, and how flexibility can be worked back into the programme.
Strategically, deans sit within the SHAs and straddle workforce and postgraduate medical education, and a large part of their input to the Tooke inquiry has revolved around workforce planning issues.
Dr Livingston says: 'We would like to see a shift to ensure medical training is much more aligned with other workforce planning. We have to balance the importance of doctor training with the fact they are also paid to deliver.'
NHS Employers and others want to see more flexibility in the system. The idea of doctors being able to change stream or move between specialties was originally built in but has been lost as MMC evolved over the years. The Tooke inquiry was asked to address this issue.
Amir Malik, chair of the Royal College of Psychiatrists trainees committee, explains why this is important for his specialty. 'A significant number of our trainees come in from another specialty,' he says. 'That's difficult to do in a rigid system.'
NHS Employers is arguing for a break point halfway through specialty training that would allow doctors to change track.
Success or not, MMC is not out of the woods yet. The BMA membership has already claimed one scalp in the form of its chairman James Johnson. Now it is aiming for chief medical officer Sir Liam Donaldson, calling for his resignation.
Chiefs may come and go; the reform potential for MMC will last a generation if Professor Tooke can keep everyone's eye on the ball.
Despite the MTAS uproar, all but a handful of medical posts were filled this year and valuable lessons learned.
Experts have warned that MTAS failures should not undermine the work of Modernising Medical Careers.
Long-term, there are calls for national screening with locally managed processes, and efforts to repair the damaged relationship with the medical profession.
View from the top
Deputy chief medical officer Professor Martin Marshall was not available for interview, but sent HSJ this statement:
'We know that August is always a quiet month with fewer outpatient appointments and fewer operations, which is why the junior doctor rotation happens at this time every year. The numbers involved were higher this time, but NHS trusts are used to dealing with this issue and have plans in place to make sure services run properly during August.
'We have also asked the NHS to make sure all junior doctors who applied through the Medical Training Application Service this year can continue to be employed as NHS doctors until 31 October.
'So thousands of doctors will not only have job security right until the end of this year's recruitment process, but will also be available to help run patient services as well.
'High-quality and safe patient care is the top priority for any clinician, whether new or experienced, and I know that doctors, nurses and managers throughout the NHS are working hard, as they always do, to maintain the high standards that patients expect.'
Modernising medical careers: a very modern history
Modernising Medical Careers dates back to the early 1990s and is an attempt to update medical education, which was perceived to be ad hoc and haphazard, relying on patronage.
It introduced a new way of training based on agreed curricula and competency assessment, with qualification in a specialty guaranteed to those who pass the assessments.
The first step was a two-year foundation programme in 2005. It aims to give newly qualified doctors the basic competencies needed to enter any specialism.
August 2007 saw the launch of run-through training in which doctors who have completed their foundation period join a specialist training programme, ultimately leading to a qualification to apply for a consultant or GP principle post.
Those who do not enter run-through training can apply for year-long fixed-term specialist training posts. After two years they may then apply to training or career posts.
The Medical Training Application Service was the process for these training jobs and in 2007 it was complicated by several factors:
the large cohort of junior doctors applying included not just those fresh out of foundation training programmes but also those part way through old-style specialist training programmes;
the large number of applicants from overseas;
it was also dogged by technical problems and concerns about its fairness and fitness for purpose.