Association of Anaesthetists of Great Britain & Ireland
As you are all no doubt aware, the implementation of MMC in August 2007 will significantly change the structure of training in all medical specialties; anaesthesia is no exception! With these changes so -lose, we thought it might be helpful to offer our views if the current state of affairs. We hope that you will not mind if we give some background to the proposed structure for those unfamiliar with the proposed changes.
The basic principle of MMC is a "run-through training" system that takes the trainee from a position of having no specialty experience all the way to a Certificate of completion of training (CCT) and entry onto the GMC's Specialist Register, although (perhaps significantly) not necessarily into a consultant post. The whole process of training is to be linked to "competencies" rather than just to time and, for that reason, all specialties have had to develop a competency-based curriculum. Fortunately 'or anaesthesia, this was already in place before these changes were even proposed. Each specialty has a ;lightly different structure, but for anaesthesia there will be a seven-year training programme, with the years designated ST1 to ST7. There will be no more SHO posts, although ST1 and ST2 will approximate to the current SHO years 1 and 2. The current timing of examinations during training will stay roughly the same. Of course, there will be in-service assessment of progress, much the same as the current RITA system, but probably with a more rigorous process for dealing with those who do not pass examinations at the expected time. Although the training is nominally of seven years' duration, some flexibility is planned in this, as it will depend upon the speed with which the necessary competencies will have been achieved. On the face of it, this seems entirely logical, but filling vacant posts is likely to prove very difficult if people complete their training early. Problems will also occur if trainees take longer than expected to finish training. Whatever the details of the system, one thing has become clear in our discussions with the MMC Board: they are only concerned with training - trainee numbers will not be adjusted to accommodate service needs.
Although the new training system will start in August 2007, the process of application and appointment is about to start. Every region will have been allocated a set number of posts and will have developed information packs for prospective candidates. They will also have gained a feel for how competitive the process will be in their area. The process will include an initial electronic submission in which the candidate has a choice of four training posts: these can be four of the same specialty in different regions or four in the same region but in different specialties, or a combination of the above. Applications will be collated and distributed to regions for scoring by local panels. Short-listed candidates will be invited for an interview that will be structured to ensure uniformity. The successful candidates will be informed of their success soon after the interviews and will start their posts in August. Unsuccessful candidates will be invited to resubmit applications for any remaining posts not filled in the first round. It would seem likely that many of these posts will be in the less popular specialties or regions.
Anaesthesia will have two possible entry portals for training. One is directly into anaesthesia; the other is through the Acute Care Common Stem (ACCS) system in which experience is gained in emergency medicine and acute medicine during a two-year programme. Any ACCS trainees then destined for a career in anaesthesia will enter anaesthesia training at the ST2 level. The numbers in the ACCS system will depend upon the numbers needed to train in emergency medicine as this is their only route of entry. The eventual specialty of anyone successful in gaining a place in an ACCS has to be determined at the beginning of their
training. In addition to the "run-through" posts, there will be a number of Fixed Term Specialist Training Appointments (FTSTAs) available. These posts will be for a maximum of two years at a level equivalent to ST1 and ST2 (cynics might suggest that these are twoyear SHO appointments in all but name). It is expected that 20% of all "training opportunities" will be in the form of FTSTAs but there is concern that that this figure will be far greater in anaesthesia. There are major concerns about the benefits of undertaking FTSTAs in anaesthesia; two years of training is not sufficient to allow independent practice, as might be required in an SAS-type post, and yet this amount of training does not allow the trainee to progress any further unless they are able to obtain a "run-through" post. This will be unlikely given the pressure to appoint into ST1 grade from the Foundation Years, and the only way a vacancy could arise in the ST2 and ST3 years will be if someone leaves the programme. The Royal College of Anaesthetists has tried hard to persuade MMC to allow four years of FTSTAs in anaesthesia in order to allow the trainees to complete their FRCA and have sufficient experience to take up a career post. So far, this has been to no avail.
Any new system is going to suffer teething problems, and there will be no exception for MMC. The main problem for anaesthesia this year is that ST1, ST2 and ST3 posts will have to be filled as the SHO grade disappears. We have been assured that there will be an increase in ST3 numbers this year to accommodate the large number of SH0s who will need to find employment, and this appears to be the case. The amount of work involved in this process will be enormous, and although the eligibilities and criteria for application to each level are still unclear, the latest advice is always available through the College website (www.rcoa.ac.uk). There are also a large number of "FAQS" in the website that cover issues such as overseas experience and academic training. We hope that there will be flexibility in this transitional period, particularly for those already embarked on a career in anaesthesia so that year 2 SH0s will not be excluded from applying for ST1 posts.
To further compound complexity, there seems to be a deal of inconsistency over what constitutes experience between the MMC apparatchiks and those working at the Postgraduate Medical Education and Training Board (PMETB). MMC is concerned about experience and competencies regardless of where they are gained, whilst PMETB will not recognise overseas training outside of a training programme. Thus, there is now a situation in which training obtained overseas will be sufficient to obtain an ST3 post, but when trainees reach the end of the training programme, they will not automatically receive a CCT and will have to use the Article 14 procedure. This seems to us absurd. It appears that there will be little or no opportunity for crossover between training posts and career posts; the only way SAS and career post doctors will be able to achieve a CCT is if they go back to the ST1 level and complete the whole training programme. However, entry onto the Specialist Register will still be available via Article 14 - in theory at least. It appears highly likely that we will move ever closer to a European or American model of training, funded by Trusts and occurring after CCT. It might be that if a hospital effectively sponsors your higher training by employing you, then part of the deal would be for you to continue to work for the hospital for a fixed period of time after completion of training. Finally, what happens at the end of training? After discussions with representatives of the MMC Board, it is clear that things are likely to be very different in the future. If you choose to stop training once you have got your CCT, it is unlikely you will be a consultant of the sort we know today. You will have achieved your "competencies" and will be eligible to practice independently, without necessarily applying for a consultant post. For example, you may choose not to enter the NHS at all and to go straight into full-time private practice. The advantage would be that you would not have to wait in line for a retiring consultant's post in an NHS that is no longer expanding. The implication is that delivery of healthcare in this country will change radically.
We have lived through the wholesale restructuring of training before. The World did not stop spinning on its axis after Calman had been imposed on us, but what is disturbing to us is the continuing uncertainty about many of the issues intimately involved in MMC, particularly with the implementation date being so close. We hope that this short overview may have given some insight into the problems without causing undue anxiety!
