Effective workforce planning must balance the training needs of doctors with the demands of the service they work in. This is not the case at the moment.
The result of the working group on specialist medical training was the Calman training scheme for all hospital registrars. Its aims were:
To meet European criteria and provide a certificate that marked the end of training (the certificate of completion of specialist training - CSST), entry to the specialist registrar grade, and thus eligibility to apply for a consultant post.
To improve and reduce the length of training by introducing a structured programme with a unified training grade (specialist registrars), eliminating the hurdle between registrars and senior registrar grades.
To control the numbers entering this training by allowing only those with a national training number (NTN) to proceed to training and hence reduce the late exit of senior registrars into career posts.
The previous system was swept away with evangelical fervour. It had been criticised because of the perceived excessive length of time to achieve a consultant post, and yet this depended on the availability of consultant posts in each specialty. In most specialties, appointments were achieved in a reasonable time. Previous arrangements were not perfect but could have been modernised.
There was inadequate consideration of how the increasing load of acute service previously carried out by registrars could be delivered. The number of specialist registrars would be reduced, and they would spend more time training and less time working. Indeed, it was apparently envisaged, usually by those far removed from clinical duties , that registrars would become supernumerary. It was thought that their work would be taken over by consultants working with senior house officers, staff and trust doctors. The Calman working party therefore correctly built consultant expansion into their equation, and assumed that registrars and senior registrars could be replaced by a '. . . significant expansion of consultant numbers'.
'The educational benefits of moving to structured and planned training cannot be realised without such expansion.'
Indeed, in 1995 Sir Kenneth Calman emphasised to the advisory group on medical and dental education, training and staffing his department's commitment to consultant expansion, which was to be a necessary precursor to the successful implementation of the proposed changes. This has not happened.
Consultants cannot and should not be expected to take on the tasks and duties of junior doctors.
This is a principle that must be robustly defended, for the consultant has different roles to play in treatment, leading clinical teams, and carrying out training, administration and research.
Staff-grade doctors are often disillusioned, poorly treated and have poor career prospects. They will presumably be drawn from specialist registrars who have failed to obtain an NTN or from doctors from abroad.
Are they simply a cheap alternative to more fully trained consultants?
A sub-consultant grade could be a solution, although this is not attractive to many in the profession and harks back to long-gone junior consultants or reincarnates the senior registrar.
3In any case, the consultant grade is expanding much less quickly than expected because responsibility for the creation of new posts has been devolved to local trusts and health authorities. Hence, only one part of the equation, namely the specialist registrars controlled centrally by the specialist workforce advisory group (SWAG), has been implemented.
Consultants are increasingly specialised, and trusts require them to spend more of their time carrying out specialised procedures to bring in income.
If the number of trainees is reduced to match more closely the current number of consultants, there will be a gap in the provision of services by trainees. In most specialties there are now more registrar posts than there are NTNs available. The difference has to be filled by locum appointments.
At interviews for entry into the specialist registrars grade, there may, for example, be eight posts to be filled, but only one NTN; the remaining posts will be filled by locums. The trainees correctly regard the local appointments for training (LATs) as a second-class job, as later they will have to compete again for an NTN, even though they have already been through one interview process. Indeed, at present many of those obtaining a LAT only have a small chance of obtaining the precious NTN, and this is deterring senior house officers from applying for hospital registrar posts.
4To rely on locum appointments, or doctors from abroad, for a large part of our service requirement is misguided and it is poor treatment of those ambitious young doctors wanting to become specialists. The policy of SWAG to match the number of trainees with projected consultant vacancies is misguided. Prediction of future needs has always been difficult, while there also needs to be some slack in the system both to provide proper competition for consultant posts and to take into account the increasing numbers of trainees who take time out or wish to work flexibly.
Allocating NTNs after the SHO stage means that we are choosing our future consultants at that time on the basis of a short interview, with little further competition later.
The new system is also too rigid so that a specialist registrar cannot in reality change to a different specialty if he wishes to alter direction , and is therefore forced almost irrevocably to choose his specialty at an early stage.
We write from the perspective of medicine, but similar problems arise in other specialties.
3Most hospital physicians are worried about how the service will be maintained. Specialist registrars are regularly required to leave their hospital during working hours to attend training sessions, forcing the cancellation of sessional work. Consultants feel unheard, in the face of the postgraduate deans who control postgraduate training and part of the funding for the specialist registrar posts.
The deaneries insist that hospital trusts are responsible for service provision and seem to regard hospitals as universities for training doctors, rather than places for treating patients.
The transition from registrar to senior registrar under the previous system had important advantages, and the competition for these posts provided a stimulus to selfimprovement.
5The new system offers only a six-month period of grace after the completion of training and the CSST, and even if a specialist registrar applies three months before completion , a post suitable to them and their families may not be available at that time.
The task of administration and audit of these complex training schemes is considerable and has been devolved to the individual training committee, namely the consultants themselves. The organisation of training and service should be under one roof and better co-ordinated.
Consultants should be given the junior support they need in order to provide a proper service, while at the same time not damaging proper training and career prospects for trainees.
One possible solution would be to increase the period as an SHO, extend educational approval for the LAT post for two years (perhaps with a different name) and then make the specialist registrar grade similar to the previous senior registrar grade. These measures could be combined with increasing the number of NTNs, including extra numbers to replace those taking time out to do research, coupled with a faster expansion of the consultant grade.
6This enlarged service would be fed by the planned increase in numbers of medical students qualifying.
Some of these possibilities are being discussed, but action is needed to avoid a manpower crisis in our hospitals.
Key points
The current system of medical manpower planning fails to balance doctors' training requirements with the demands of the NHS. Urgent action is needed to avoid a manpower crisis.
Specialist registrars regularly have to leave their hospitals for training sessions, forcing the cancellation of sessional work.
Hospital medicine is relying heavily on locums and doctors from abroad.
Consultants should be given the junior support they need in order to provide a proper service, possibly through increasing the time spent at senior house officer level.
Dr Robert Elkeles is consultant physician, St Mary's Hospital, London; Dr Richard Thompson is consultant physician, St Thomas' Hospital, London.
REFERENCES 1.Hospital doctors: training for the future. The report of the working group on specialist medical training. London.
Department of Health. 1993. See also Unified Training Grade. Report of the Working Party on the Unified Training Grade. DoH. 1994.
2 Mather HM, Elkeles RS. Attitudes of consultant physicians to the Calman proposals: a questionnaire survey.Br Med J 1995; 311: 1060-2.
3 Hobbs KEF. Specialist training in the UK. Lancet 1997; 350: 1851.
4 Galasko CSB, Jackson B. Insecurity about progression is an added stress for senior house officers. Br Med J 1999; 318: 5345.
5 Elkeles RS. Specialist training in the UK. Lancet 1997; 350: 1851.
6 Thompson RPH. The medical career structure in 1985. J R Coll Physicians Lond 1985; 18: 31-33.
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