British doctor-training fiasco

The head of a controversial scheme for training doctors was ejected from office yesterday by the sheer weight of medical opinion. Professor Alan Crockard resigned as national director of Modernising Medical Careers (MMC) over the failure of the system for selecting junior doctors for training jobs. Critics say that the system is so unreliable that excellent doctors will be rejected and poor doctors appointed, damaging the quality of care and risking patients’ lives. Junior doctors and consultants have condemned the Medical Training and Application Service (MTAS) as unfair and incompetent. The recommendations of a review panel set up to rescue the process were rejected by junior doctors.

Professor Crockard has resigned with immediate effect. Lord Hunt of Kings Heath, the Health Minister, said: “I would like to thank Alan for his enormous contribution to Modernising Medical Careers. “Alan’s work led to the successful establishment of the Foundation Programme for the early years of postgraduate medical training, which has been widely acknowledged to be a success. I appreciate that it has been a difficult time for junior doctors and would like to reassure them that we are listening to their concerns and working with their representatives to find a fair solution to this complex issue. “I would like to reconfirm our commitment to MMC which aims to recruit and train the best doctors to provide the best possible patient care.”

Professor Crockard, a neuro-surgeon, was recruited in 2004 to run MMC, a system for revamping medical training. This turned the old system upside down, replacing what amounted to an apprenticeship with a scheme designed to teach and measure competencies in all branches of medicine. While many doctors have doubts about MMC, believing that it is narrower and less flexible than the old scheme, it was the failures of the computer-based MTAS — a small part of the system — that brought Professor Crockard down. Last year, when the first doctors to be trained under MMC graduated, there was a huge row about the failures of the computer system to place them reliably into junior doctor posts, known in the MMC jargon as F1 and F2 posts.

But the problems were as nothing compared with those that occurred this year, when the task was to place junior doctors in training posts that would lead eventually to consultant positions. More than 30,000 were competing for 22,000 places. Success would put them on course to become consultants, failure could mean a blighted career. The computer could not cope with the volume of applications, limited the applications the junior doctors could make and failed to produce adequate shortlists for interviews. Many outstanding candidates failed to get any interviews in the first round because the application forms failed to recognise academic excellence adequately. Others were shortlisted despite not being qualified for the jobs.

The Department of Health appointed a panel to try to rescue the process, but its recommendations have not found favour with junior doctors. Dr Matthew Jamieson-Evans of Remedy UK, the body that organised mass medical protests in London and Glasgow over MTAS, said: “Resigning is the honorable thing for Professor Crockard to do. We bear no personal ill-will to him, but it is right that somebody should take responsibility. “This is only the first chapter. Very very few doctors are happy with the recommendations of the review panel.”

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Big Australian public hospital in trouble

THE Royal North Shore Hospital is lurching towards another crisis, with a senior doctor resigning over serious problems with trauma surgery as the troubled hospital struggles to rein in its budget and maintain services. His resignation comes as the hospital's ability to manage elective surgery was again called into question by revelations yesterday that a woman booked to have fibroids removed had her operation cancelled twice on the day of surgery.

Over the past 10 years the surgeon, who does not want to be named, has written letter after letter, detailing a litany of complaints and cover-ups at the hospital, which he says has failed to properly investigate any of the incidents. "The system allows multiple problems to occur," his resignation letter says. "There is no one person who takes ownership of the problem and has the ability to affect any change for the good of those individual patients who are being harmed by the system." Obsessed by process at the expense of health care, the hospital gave medical and surgical units "untenable service goals with limited resources", he said. "We are exposed to a rotating door of middle managers who are servants to a paperwork process that hides the problem."

The final straw came when a patient arrived at the emergency department with a severe fracture and other complications but was refused access to theatre - and only received surgery five days later.

The resignation comes just two months after the Herald revealed that the hospital was facing another significant budget overrun, with an audit finding that $30 million of essential equipment needed to be bought. "North Shore is over-budget," admitted Phillipa Blakey, the director of clinical operations of Northern Sydney Central Coast Health. "It is not as over-budget as it has been in the past . and in terms of the area, we will break even at the financial year." She pointed to a fall in the rate of cancellations on the day of surgery from 18 per cent last July to 5 per cent last month, as well as a reduction in the number of people waiting longer than 12 months for surgery from 61 to seven in the past year. "It is a very busy hospital and it is getting busier by the day . And despite that the performance has improved a lot."

The chairman of the Royal Australasian College of Surgeons in NSW, Phil Truskett, said: "It is no different throughout metropolitan hospitals in NSW and if you want to get into rural and remote NSW it is much worse." A lack of infrastructure and funding was hampering access to operating theatres for acute cases, affecting the patients involved and those waiting for elective surgery, Dr Truskett said. "Acute surgery is done in the middle of the night when it should not be done - we need an appropriate process and method of managing acute care during the day."

The president of the Australian Medical Association in NSW, Andrew Keegan, said patient care was suffering because the system was being run to make the numbers look better. "If someone senior doesn't take responsibility for that patient then the quality of care is at risk," he said.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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