The Medical Training Application Service (MTAS, pronounced em-tass) was an on-line application system set up under the auspices of Modernising Medical Careers in 2007 and used for the selection of Foundation House Officers and Specialty Registrars, and allocating them to jobs in the UK.[1] Its implementation was heavily criticised both in the press and within the medical profession, and its operation was marked by the resignation of key staff and serious security breaches. The system affected junior doctors, and so every qualified doctor in the UK who had not yet attained Consultant status.
Prior to the introduction of Modernising Medical Careers (MMC), junior doctors who had completed their initial training after medical school (formerly the Pre-registration house officer or PRHO grade) could apply for posts as a Senior House Officer (SHO). They could apply for as many posts as they wished, and would be selected by their future employers based on their CV / application form and interview. They could devise their own training programme or apply to be part of a training rotation – usually entailing changing jobs every six months, but staying within the same speciality and hospital. Whilst training, an SHO would be encouraged to take professional exams to enable them to become a member of one of the medical royal colleges. Once this was achieved, they could apply for jobs as a specialist registrar. The lack of formal structure between the PRHO grade and the specialist registrar grade led to SHOs being labelled as a "lost tribe".[2] During the MTAS crisis, however, "The Lost Tribe" was used to refer to doctors who were not able to proceed using the new computer system and as a result were left with no career at all, and so in a worse situation that the original "Lost Tribe" the system had been intended to help.
MTAS application process
Under MTAS, junior doctors who had completed the PRHO grade, and more recently the Foundation House Officer grades, along with those who already had up to several years of experience working at the old SHO (next grade up) level, were invited to submit an electronic application form on the MTAS website. Applications could be made to one speciality in four geographic areas (called 'Units of Application' or UoAs), or to two specialties in two UoAs, or four specialties in one UoA. There were twelve geographical areas: one each for Scotland, Wales and Northern Ireland; one covering the whole of London, Kent, Surrey and Sussex; and eight others. The completed application forms were used for selection for interviews. Candidates who were not eligible (for example, not having practised medicine for a number of years, or not being registered with the UK General Medical Council) were rejected at the 'longlisting' stage, with the 'shortlisting' stage designed to pick out the best applicants.
Scoring of applicants
The application form consisted of shortlisting questions with space for 150-word answers. One of the changes promoted by the new system was that little (25%) importance was given to past experience, achievements, or examinations passed in the specialties, while the majority of the weighting for selection was based on the 150-word answers in the electronic application form (75% weighting). This was in sharp contrast to the previous CV-led process where past experience, achievements and examinations passed in the specialties were used to shortlist candidates for interview.
The questions on which the majority of the score was based were heavily criticised both at the time by the medical professionals obliged to answer them and subsequently in the independent review of MMC led by Professor John Tooke. The report commented:
"Free-text boxes encouraged plagiarism and commercial websites sold responses. Plagiarism was common but the promised plagiarism software did not function initially. Even when it did, plagiarism detection was relatively unhelpful as it could identify similar responses but could not identify whether the applicant composed or copied the text and thus could not be used to exclude applicants. In addition, the word limit was felt to be too restrictive by many.[3]
Shortlisting was widely regarded as uneven and unfair, with the Tooke Report noting: "Some excellent candidates not shortlisted. Many very poor candidates were shortlisted."[3] A number of local schools withdrew from the process in protest, with the North Central London School of Anaesthesia noting "It is our professional duty as shortlisters to make sure that the appointment process is carried out correctly and that all candidates are considered equally and fairly. There have been a series of serious procedural errors during the process[...]There has been a general recognition that round 1 of MTAS has been unfair and ineffective."[4]
Interviews
The interviews were again designed to be unbiased, in that, once selected for interview, the application form would be ignored, and CVs would not be allowed at interview. Instead, defined questions with explicit marking schemes gave scores to the candidate's answers by looking for certain phrases and keywords. Again, the emphasis here was on removing possible bias due to a candidate's past achievements and experience, and focusing only on the performance at the standardised interview.
As with other areas of the scheme, the interview process attracted several criticisms at independent review as they were "felt by many to be too formulaic and politically correct rather than sufficiently probing to demonstrate differences in competencies and abilities", they were frequently too short ("In many cases the time allocated to interviews was the minimum of 30 minutes which some interviewers felt was insufficient"), and they failed to reward those with high academic achievements, who "were particularly disadvantaged by a non-CV based process."[3]
After the first round of interviews, there was a plan for a second round of applications. Candidates who were unsuccessful in both rounds would have no further opportunity to gain access to a training job in the UK for the year ahead, as MMC meant it was impossible to recruit junior doctors after the single specified start date.
Application forms were released in February 2007, with two weeks to complete and submit. The first round of interviews were due to be carried out in February, March, and April 2007 with applicants finding out whether they were successful in May. The second round was to take place after this, finishing in late June 2007.
Theoretical benefits of MTAS
In theory, the new application system centralised the application process, reducing the workload for consultants in shortlisting candidates for interview, and the workload of candidates applying multiple times for different posts.
Unfortunately in practice the centralised system failed, with MTAS withdrawn after the matching process, and the workload for consultants was hugely increased, as evidenced in several of the resignation letters prompted by the procedure: "The Consultants involved in shortlisting have all worked long hours, often at weekends or during half term holidays, and have done their utmost to cooperate[...]Most of us had 48 hours in which to carry out shortlisting of up to 650 applications.".[4]
Problems with MTAS
Theoretical problems
Theoretical concerns behind the process include:
The MTAS system was based on five academic papers all produced by Fiona Patterson.[5][6][7][8][9] The papers were based on a very small sample size and made clear that the correlation between successful completion of the MTAS form and having the competencies required to be a successful doctor was 0.35, or poor.
It was decided to make a 'clean break' with the old system of Senior House Officer training by making all SHOs currently in training apply through the system. These doctors were between six months and six years into their training in a particular speciality. Many had higher qualifications such as membership of the Royal College of Physicians (MRCP) or had taken part in research in their chosen speciality. It was a common misconception amongst more senior colleagues that SHOs would essentially be reapplying for their old jobs. Given the centralised nature of the selection process, this was not the case. Tabulation of the number of jobs at each level revealed that there were far fewer posts in the upper ranks of training than there were doctors already at that stage,[10] which left many doctors partially trained and without a career under the new system.
Since geographical units of application were so large, candidates had to be prepared to work in a huge area of the country, or to compromise on their speciality since they were warned that making fewer than four choices would place them at a disadvantage. This was extremely hard for those who had family or financial ties.
Because interview and selection took place centrally, rather than at the employing institution or hospital, specialist institutions had no input into the particular skills and attributes needed to work in particular posts.
An application via MTAS was seen as an endorsement for Modernising Medical Careers, leading to a moral dilemma for those disagreeing with the system but obliged to apply in order to have a chance of a job.
Implementation problems
The system used horizontal marking, whereby each of a single candidate's responses were marked by a different set of markers. Unfortunately, candidates were not informed that this would occur, and many had assumed the entire form would have been marked by the same markers. Consequently, candidates that cross referenced their answers across the form (e.g., by writing "as detailed in my answer above") failed to score marks compared to candidates who did not do this.
The online application system frequently became overloaded which meant that potential applicants were unable to log into the site, complete or submit their forms. The application deadline was extended by 48 hours to enable candidates to submit their forms[11]
Some forms were "lost" in the online system, and parts of other forms were not visible to markers.[3][4]
The "double-blind" system for marking failed. Each form should have been marked independently by two consultants to ensure mistakes by one marker are covered by the second marker. Unfortunately, some forms were only marked by one consultant.[4]
Not all forms were marked by consultants. Many deaneries asked non-medical staff to help them meet their deadlines. It is unclear whether these non-medical staff were appropriately trained to mark the papers, and whether applicants were disadvantaged or advantaged if their forms were marked by non-medical staff.
Exceptional candidates received no interviews. A large proportion of candidates who had already passed professional exams, had PhDs or research experience in the relevant speciality and many with considerable clinical experience were not shortlisted for interviews.[3] This was largely due to the weighting of questionnaire responses over academic and clinical achievements.
Security concerns
The security of the system failed, with personal details including phone numbers, home addresses and sexual orientation of junior doctors publicly available for several hours to anyone with the right URL.[12] The following day it was reported that applicants had been able to see each other's files by changing two digits in the personalised web address given to each individual, and the system was suspended.[13]
Attempts to repair interview process
The allegations of widespread execution problems led to a review and a rolling program of sweeping changes, leaving the junior doctors in the system unsure of where they stood for long periods. The review stated that everyone should be entitled to keep any previous interviews in hand and also have an interview for their first choice if this was in England, with Wales and Scotland deciding to interview all applicants for all posts. Applicants for English programmes were able to make any of their four initial choices into their new first choice if they wished, in order to maximise the number of interviews they would have. This extra round of interviews was called Round 1B. Estimates are that there were 30,000 extra interviews requiring at least 15,000 consultant hours of interview time[citation needed].
The initial offers from Rounds 1 & 1B were made by 10 June 2007. Round 2 started on 22 June and was organised locally as the MTAS system was offline. Round 2 continued until 31 October 2007, three months after the process should have been completed. The guidance from MMC indicated that any junior doctor in substantive employment on 31 July, and taking part in Round 2 will be guaranteed employment until the end of Round 2 in October, "Please note that all applicants who applied to MTAS who are in substantive NHS employment on 31 July will continue to have employment while they progress through Round 2".[14]
There was, however, a general feeling amongst those involved in the system that it was beyond repair and further efforts to do so constituted an example of 'irrational escalation'[citation needed].
Repercussions
The British Medical Association (the largest trade union body representing doctors) pulled out of the review panel after their announcement that each doctor would only be given one interview.[15] Organisations like the Royal College of Surgeons stated that they had lost confidence in the system.[16]
The BMA later rejoined the review and have since lent their support to the proposed changes ("Round 1B"). However, following an outcry by members and a controversial letter[17] to The Times newspaper, Mr James Johnson, Chairman of the BMA resigned on 20 May 2007, citing his reasons for leaving as the contents of the letter.[18]
On 30 March 2007 Professor Alan Crockard resigned as National Director of Modernising Medical Careers. In his resignation letter[19] he stated that he has "responsibility but less and less authority" and that "the overriding message coming back from the profession is that it has lost confidence in the current recruitment system".
On 3 April 2007, during an interview on BBC Radio 4's Today programme, the Health Secretary Patricia Hewitt apologised to junior doctors over the crisis, saying that the application scheme had caused "needless anxiety and distress". The British Medical Association welcomed the government's acknowledgement of the problem but stated that "an apology isn't enough".[20] Patricia Hewitt's apology was repeated to parliament on 16 April 2007, however she stated that, "the problems that have arisen relate in the main to the implementation process and not to the underlying principles of Modernising Medical Careers."[21] Later that month Ms Hewitt was accused by the opposition of failing to express genuine regret over the fiasco.[22]
The MTAS website was suspended on 26 April 2007 after a Channel 4 News report stated that applicants had been able to see each other's files by changing two digits in the personalised web address given to each individual.[23] At that point the Department of Health announced that this was a temporary suspension.[13]
Ms Hewitt made another apology on 1 May 2007 in the House of Commons after the suspension of the MTAS website due to security breaches that she described as "utterly deplorable".[24] On 3 May, Hewitt appeared on BBC Question Time where she faced hostile questioning from a junior doctor over MTAS failures.[25]
On 15 May 2007 MTAS was shelved by ministers due to security breaches. Patricia Hewitt said that after the first round of recruitment, the system would only fulfil a monitoring role.[26]
A judicial review of MTAS was successfully called for by pressure group Remedy UK, who demanded that the appointments process should be scrapped altogether. The case was heard in the High Court from 16 to 17 May 2007, where the BMA sided with the government despite an overwhelming majority of their own membership opposing MTAS.[27] On Wednesday 23 May 2007 Mr Justice Goldring ruled against Remedy UK, stating that "although far from ideal", the Review Group's decision on amending the appointments process after the first round of interviews was "within the range of reasonable responses", and that the Review Group was "entitled to reach the decision it did given the circumstances facing it at the time". Although he ruled against invalidating the interviews that had already taken place, Mr Justice Goldring added that this judgement did not imply that junior doctors were not entitled to feel aggrieved, as "the premature introduction of MTAS has had disastrous consequences". Remedy UK have said they will not appeal the verdict, in order to avoid further uncertainty for junior doctors.[28][29][30]
Patricia Hope Hewitt is an Australian-born British government adviser and former politician who A member of the Labour Party, she served in the Cabinet from 2001 to 2007, latterly as Secretary of State for Health.
The Department of Health and Social Care (DHSC) is a department of His Majesty's Government responsible for government policy on health and adult social care matters in England, along with a few elements of the same matters which are not otherwise devolved to the Scottish Government, Welsh Government or Northern Ireland Executive. It oversees the English National Health Service (NHS). The department is led by the secretary of state for health and social care with three ministers of state and three parliamentary under-secretaries of state.
The British Medical Association (BMA) is a registered trade union for doctors in the United Kingdom. The association does not regulate or certify doctors, a responsibility which lies with the General Medical Council. The association's headquarters are in Tavistock Square, London and it has national offices in Cardiff, Belfast, and Edinburgh, a European office in Brussels and a number of offices in English regions. The BMA has a range of representative and scientific committees and is recognised by National Health Service (NHS) employers as the sole contract negotiator for doctors.
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In the United Kingdom, junior doctors are qualified medical practitioners working whilst engaged in postgraduate training. The period of being a junior doctor starts when they qualify as a medical practitioner following graduation with a Bachelor of Medicine, Bachelor of Surgery degree and start the UK Foundation Programme, it culminates in a post as a Consultant, a General Practitioner (GP), or some other non-training post, such as a Staff grade or Associate Specialist post.
See: Medical Schools in Wales
A senior house officer (SHO) is a non-consultant hospital doctor in the Republic of Ireland. SHOs are supervised in their work by consultants and registrars. In training posts these registrars and consultants oversee training and are usually their designated clinical supervisors.
Medical education in Australia includes the educational activities involved in the initial and ongoing training of Medical Practitioners. In Australia, medical education begins in Medical School; upon graduation it is followed by a period of pre-vocational training including Internship and Residency; thereafter, enrolment into a specialist-vocational training program as a Registrar eventually leads to fellowship qualification and recognition as a fully qualified Specialist Medical Practitioner. Medical education in Australia is facilitated by Medical Schools and the Medical Specialty Colleges, and is regulated by the Australian Medical Council (AMC) and Australian Health Practitioner Regulation Agency (AHPRA) of which includes the Medical Board of Australia where medical practitioners are registered nationally.
Modernising Medical Careers (MMC) is a programme for postgraduate medical training introduced in the United Kingdom in 2005. The programme replaced the traditional grades of medical career before the level of Consultant. The different stages of the programme contribute towards a "Certificate of Completion of Training" (CCT). It has been dogged by criticism within and outside the medical profession, and an independent review of MMC led by Professor Sir John Tooke criticised many aspects of it.
Medical education in the United Kingdom includes educational activities involved in the education and training of medical doctors in the United Kingdom, from entry-level training through to continuing education of qualified specialists. A typical outline of the medical education pathway is presented here. However training schemes vary and different pathways may be available.
A specialist registrar (SpR) is a doctor in the United Kingdom or the Republic of Ireland who is receiving advanced training in a specialist field of medicine in order to become a consultant in that specialty.
In the United Kingdom, Ireland, and parts of the Commonwealth, consultant is the title of a senior hospital-based physician or surgeon who has completed all of their specialist training and been placed on the specialist register in their chosen speciality. Their role is entirely distinct from that of general practitioners, or GPs.
An NHS deanery is a regional organisation responsible for postgraduate medical and dental training, within the structure of the National Health Service (NHS) in Scotland, Wales and Northern Ireland. In 2013, restructuring of the NHS in England led to its deaneries being incorporated into new bodies, known as Local Education and Training Boards (LETBs), that have taken over these functions.
Remedy UK was a pressure group representing junior doctors in the United Kingdom. The organisation was set up by four junior doctors in 2007 to campaign against UK government-led medical training reforms known as Modernising Medical Careers(MMC) and their implementation through the Medical Training Application Service (MTAS). Remedy UK was created in response to what was perceived to be an insufficiently robust response by the official doctors' trade union, the BMA, and professional associations.
A specialty registrar (StR) is a doctor, public health practitioner or dentist who is working as part of a specialty training programme in the UK. This is known as a training grade as these doctors are supervised to an extent, as part of a structured training experience that leads to being able to undertake independent practice in a hospital specialty or working as a general practitioner.
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Sir Liam Joseph Donaldson is a British doctor. He was formerly the Chief Medical Officer for England, being the 15th occupant of the post since it was established in 1855. As such, he was principal advisor to the United Kingdom Government on health matters and one of the most senior officials in the National Health Service (NHS).
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