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The Tooke Report is 240 pages long, the Department of Health (DH) response is 70 pages.

It is not surprising, therefore, that many colleagues may not have read them! Those colleagues should take the time – the breakdown of the Medical Training Application System (MTAS) and Modernising Medical Careers (MMC) has dominated many of our lives for the past year and the report provides compelling, if troubling, insights into the errors which have undermined the central co-ordination of both initiatives.

Its recommendations have been largely accepted by the Secretary of State for Health. This is liable to have wide-ranging implications for the shape and focus of postgraduate medical training in coming years. There are particular considerations for postgraduate training in Geriatrics.

Attracting Specialty Trainees
Specialist Trainee (ST) rotations in Geriatrics have been well subscribed since MTAS, however surveys of qualified geriatricians suggest that they tend to have chosen geriatrics late in their medical training, often after working or training in other specialties. The rigidity of the original MMC model led to concerns that trainees would choose geriatrics without adequate consideration or, for “the wrong reasons”. This, in turn, might have ramifications for job satisfaction, performance and retention of trainees.

Flexibility lies at the heart of many of Tooke’s recommendations – the report suggests increased opportunity to move between core medical training stems and increased modularity of higher medical training – perhaps affording more opportunity for trainees to gravitate towards geriatrics later in their careers. These recommendations, however, remain under consideration by the DH and quite how flexibility will be accommodated within workforce planning remains unclear.

Workforce planning
The current cohort of SpRs and ST3s in geriatric medicine face uncertainty surrounding consultant appointments post-CCT. Last year, 58 consultant posts in geriatric medicine were advertised, whilst 103 CCTs were completed. There is, however, no evidence of large-scale unemployment amongst CCT holders and it is believed that a significant number are now working as consultants in acute medicine. However, as the number of acute medicine SpRs completing training increases, it is unclear how the shortfall in consultant geriatrician posts will be accommodated in the future.

The Tooke report identifies the inadequacy of current NHS workforce planning models and suggests improvement in these, informed by a database of CCT holders, held co-operatively between the DH and General Medical Council (GMC). More importantly, it identifies the need to make workforce planning data available to trainees whilst making careers choices. This should allow closer mapping of supply to demand and allow trainees to modify career aspirations in light of the probability of consultant appointment. This will be of little reassurance to the current SpR cohort but hopefully will provide increased certainty in the future.

Evidence-based policy
The enquiry makes much of the need for a proper evidence-base for future policy decisions affecting changes to training and career pathways. Geriatrics remains a vanguard specialty in the move to knowledge based assessment (KBA) and workplace based assessments (WBA) for specialty trainees. There has been considerable debate around the evidence base for these assessments. Five out of seven WBA assessment tools are the subject of ongoing validation in higher specialist training, whilst questions over validity continue to dominate trainee meetings about Knowledge Based Assessment (KBA). If measures to validate these are unsuccessful, this will provide a significant challenge to the spirit of the Tooke recommendations and a dilemma as to how to proceed.

Non-consultant career grade doctors
With regard to the significant number of non-consultant career grade doctors within the specialty, Tooke recognises a need for destigmatisation, a right to protected training and the need for a limited number of applications to proceed to CCT. This will be influenced significantly by the provisions of the Staff and Associate Specialists contract and how these suggestions can be effectively delivered remains to be seen.

If adequate provisions for training are made and supported with effective appraisal mechanisms, this should allow co-ordinated preparation for application to the specialist register – which in turn will maximise the chances of successful application.

Undergraduate Considerations
Tooke recognises the need for early career planning in medical school to match doctors’ aspirations with the needs of the NHS. Attracting high quality applicants to geriatrics may continue, therefore, to depend upon the quality of undergraduate teaching in geriatric medicine. Ongoing work to assure the quality of undergraduate teaching therefore continues to be important.

Academic Careers
Much has been made of the need for high quality applied research in ageing. Academic geriatricians have a significant contribution to make. Prof Crome, in his submission to the House of Commons Health Committee Inquiry, raised concerns about the possible negative impact on academic training imparted by the relative inflexibility of MMC.

Tooke praises the academic arm of MMC as being largely successful but recommends increased flexibility to allow movement of trainees between academic and clinical workstreams. If correctly facilitated, this provides the potential to dramatically increase the number of CCT holders with academic exposure – allowing the specialty to remain at the centre of ageing research.

Continuity of care
Elderly patients are complex and benefit considerably from close continuity of care. Tooke recognises the negative impact the European Working Time Directive has had on this and asks the DH to consider ways in which a more flexible model of working can be embraced. This has received a mixed reception amongst junior doctors’ groups and the DH is yet to develop a programme of work to address the issue.

These are early days and although the DH has responded favourably to the report, there remains considerable uncertainty as to how and when individual recommendations will be adopted. Many recommendations, although accepted in spirit, do not yet have an allocated programme of work. The period of uncertainty continues. The report, however, provides a glimmer of hope for increased flexibility, more job certainty, more effective progression for SASGs and the promise of a search for evidence before future changes to our career structure. Let’s hope it works!

Adam Gordon
Trainees Representative
BGS Education & Training Committee

BGS Newsletter, May 2008
Issue 16 ISSN 1748-6343 16